Integrating Psychology and Primary Care

More than a century ago, Sir William Osler articulated the value of blending psychology and medicine. Among his many insights was a holistic focus on care of the person, not just the disease. Psychologist Carl Rogers further developed this concept in the 1940s, prescribing empathy and unconditional positive regard for truly “person-centered” care. Yet decades later, while discussion continues, data suggest these concepts are easier to describe than deliver. At the root of this challenge is limited clinical integration of psychology and medicine.

Communication: a very hard “soft” skill

Consider, for example, while communication has often been labeled a “soft” skill within medicine, most evidence has actually shown it to be “hard.” Communication gaps persist between clinicians and patients when discussing limited prognoses, terminal diagnoses, and many other areas of uncertainty and discomfort, such as driving capacity, suicidality, sexuality, substance use, and death. Another layer of complexity is the fact that the majority of communication is nonverbal (e.g., body language). Though trainable and learnable skills, therapeutic communication techniques can be difficult to translate into an algorithm, decision tree, or set of guidelines (though this continues to be attempted). And even with these tools, clinicians in distress may continue using avoidance to cope.

Modeling these skills

Thus, my goal with both patients and medical learners has been to directly address these challenges by modeling skills such as active listening and empathy, stimulating reflection, and enhancing self-awareness, all in a non-threatening, clinically relevant way. For trainees, this ideally results in greater confidence to address, rather than avoid, ambiguity, and greater ability to connect deeply with patients and families.

Below are examples of how I’ve tried to integrate psychology and medicine clinically:

Teaching at the bedside

Consistent with Osler, I have tried to deliver teaching at the bedside whenever possible. Even during didactics, this has included patients and caregivers as co-instructors, particularly vital when teaching psychological aspects of care that can otherwise be misconstrued as abstract or even irrelevant. In one example, I invited Mr. V, a clinic patient, to the hospital to co-deliver noon conference. On paper, Mr. V appeared poor, Hispanic, in the US illegally, formerly incarcerated, and because of complications from an infection several months earlier, had nearly died. But during our presentation, which focused on his resilient mindset and distrust of physicians, the residents realized he was also acutely vulnerable. This forum at once humanized and de-stigmatized the patient, who, sight unseen, based solely on his chart, could have been labeled in a derogatory or biased manner. Similar impact was felt after hearing from Ms. W, a 92-year-old widow who, chronically ill, frail, bored, and isolated, felt ready to die. She was frustrated by physicians she deemed too uncomfortable to discuss these concerns with her.

I also invite residents to shadow me during outpatient encounters. For some residents, this is their first experience working with a psychologist. In one case, a young female resident continued to gasp, audibly, as a young female patient described numerous episodes of sexual trauma, and her unhealthy, maladaptive attempts to cope. In another example, a confident resident presented a patient, emphasizing the need to gain better control of his hypertension. The chart stated the patient had previously been counseled about risky sexual behavior and undergone HIV testing. Thus, I asked the resident about the patient’s sexual orientation and whether the patient’s roommate was male or female. The resident now seemed less confident and could not answer either question. As we re-entered the exam room and I took the patient’s history, the resident was startled to learn the patient was gay, fled his home state to escape abuse, self-medicated with drugs and alcohol, attempted suicide several times, and was currently contemplating buying a firearm. Another resident was similarly surprised when she observed my interview of a 19-year-old morbidly obese patient, recently started on diabetes medication. The resident felt confident she could cure the patient with reduced-cost bariatric surgery. But during our interview, she realized things were more complicated, as both she and the patient shed tears while the patient admitted her overeating and self-isolating behaviors were attempts to cope when her parents, with whom she lived, became violent.

Curiosity instead of judgment

In our current era of clinical practice, where burnout is commonplace, I have intentionally tried to empathize with learners and model curiosity rather than judgment. For example, when I checked in with Dr J, a future cardiologist, about his new patient, he replied “nothing of interest to you Doc.” Doubtful, I did not correct him I simply inquired further about the patient’s presenting problems. The resident pointed out several vascular risk factors and, while chuckling, stated “his heart would be better if he’d just stop smoking.” I acknowledged and validated the resident’s frustration, and probed about the patient’s cultural background, occupational status, and most importantly, why he smoked. As the resident reflected upon this in the moment, he had difficulty answering. After several moments of silence, he then remembered the patient disclosed being under stress. In fact, the patient was  impoverished, chronically anxious, and recently unemployed. To show the resident how prevalent this pattern is, we reviewed empirical articles on anxiolytic use of smoking within this population, and discussed national initiatives targeting other social determinants of health.

Life and death 

Perhaps the most gratifying example of learner-centered teaching occurred with intern Dr. G, who was disheartened by what he perceived to be clinician indifference when patients died. When he said to me that no one cared, rather than argue or challenge him, or worse, reassure and convince him otherwise, I listened with empathy and curiosity.

Dr. G described various clinical cases where he believed suboptimal management led to potentially avoidable fatalities. When I asked how he knew no one cared, he was unable to answer. After a lengthy silence, he finally pointed out that clinicians witnessing death never commented or showed any emotion. I suggested these were superficial but protective coping mechanisms that hid a more complex reality, and shared published articles acknowledging the same.

I invited him to co-present about medical training, death and dying, along with several 4^th-year medical students and a geriatrician colleague. At the conference, I encouraged the learners to share their truths openly, and reiterated how important their voice was. As predicted, the presentation struck a chord with the audience members, several of whom disclosed their own personal experience with death. This validated the learners’ frustrations, and helped reshape their perceptions that emotional sensitivity was an asset, not a liability.

Months later, Dr. G texted me with pride after successfully resuscitating a middle-aged patient while others had called the code assuming the patient had died. In the hospital, he pulled me aside privately and confided, “the only reason I had the confidence to continue chest compressions was that conference.”

More recently, one of our student co-presenters (now a second-year resident) forwarded an email from his program director awarding him “colleague of the month,” and he thanked me for my end-of-life training.  Included in the email were medical details of a frail, multimorbid, geriatric patient with whom the resident conducted a thorough goals of care conversation that resulted in non-invasive management and a comfortable death consistent with her wishes.

Person-centeredness – be it learner-centered training or patient-centered care – holds great potential to maximize healing in the way Osler envisioned more than a century ago. But to translate this concept clinically, psychology and medicine must come closer together. The closer we can come together, the closer we can come to Osler.