Are you insulted when a physician colleague types on a computer screen while you're talking? Or do you acknowledge that physicians are so pressed for time that they must try to multitask?
When a surgeon asks for your opinion of a patient, do you present her with an eight-page report detailing the patient's psychological history? Or do you get straight to the point?
Do you come to a 7:00 a.m. meeting at 7:15, muttering an excuse about traffic? Or do you show up on time as a sign of respect for your team members?
If you're a psychologist working in an integrated health-care setting, how you answer these and other questions can affect effective team functioning and the collaboration at the heart of integrated settings that allow psychologists, physicians and other clinicians to work together for the good of shared patients.
And given the difference between medicine's culture and psychology's, you may not even know when you're stepping on team members' toes.
As psychologists increasingly move into primary-care practices, hospitals and other health-care settings, they need to know the expectations for how to interact with colleagues and their patients.
When psychologists are "living in medicine's house," they need to take their cues from the other health-care professionals around them, says John C. Linton, PhD, associate vice president for health sciences and dean of West Virginia University's School of Medicine in Charleston. That might mean wearing a white coat, being comfortable talking with a patient in a hospital gown or simply being more succinct than you're used to, say Linton and other psychologists who work in integrated-care settings.
Unfortunately, says Linton, etiquette is a missing ingredient in most psychology education and training programs, even those with an emphasis on preparing students for integrated-care settings. He and others share these tips on how psychologists working in such settings should interact with colleagues and patients:
1. Be appropriately assertive
Some psychologists who join integrated-care teams feel intimidated by physicians, even those their own age, says psychologist Susan H. McDaniel, PhD, a professor of psychiatry at the University of Rochester Medical Center. And if they're introverted by nature, it can take practice to speak up, says McDaniel. She role-plays with her students so they become comfortable defining their roles and projecting their expertise. If a psychologist is too quiet, she says, colleagues may be thinking, "She's analyzing me."
That said, it's important not to "come in with guns blazing," says Nancy Ruddy, PhD, who directs an integrated primary-care psychology postdoctoral fellowship program at Montefiore Health System and consults with practices transforming themselves into integrated settings. "When you go into a new setting, you just have to approach it as if you're a stranger in a strange land," says Ruddy. Instead of broadcasting your expertise right away, which can be off-putting, be humble. "You're there as a learner first," she says.
2. Take your lead from your environment
Medicine's culture differs from psychology's culture, says psychologist Jodi Polaha, PhD, an associate professor of family medicine at East Tennessee State University who provides services to low-income rural patients at the university's outpatient clinic. Psychologists, she says, can inadvertently irritate colleagues by using psychological jargon instead of clear language, dressing informally when physicians wear suits and lab coats or accidentally disrupting patient flow. If a physician wants to check a patient's lab results before the patient leaves, for example, don't insist on seeing the patient before he or she gets blood drawn.
To avoid such misunderstandings, Polaha suggests that when psychologists first join an integrated team, they should spend a week shadowing various health-care providers and observing front-desk staff, who are often the first to notice patients in distress. "Shadowing them gives you a full sense of the culture," says Polaha. "This lets you truly appreciate where they're coming from in terms of the language they use and the demands they have." It also enables you to identify what problems they have that you can solve.
Keep in mind that norms can vary even within the same institution, says Lauren N. DeCaporale-Ryan, PhD, an assistant professor of psychiatry, medicine and surgery at the University of Rochester Medical Center. Take levels of formality, for instance. "I'm Dr. DeCaporale-Ryan in the departments of surgery and medicine," she says. "In family medicine, I'm Lauren." The same goes with attire, with suits and a white coat expected in the surgery department but not in family medicine. Other psychologists don white coats to command authority in settings where physicians dominate but ditch them in their own offices to avoid provoking anxiety in some patients.
Each clinician has his or her own communication preferences, too. Some physicians want to receive messages from psychologists via the electronic health record (EHR) system, for example. "Other physician colleagues say, ‘If you send me something in the EHR, it will just be lost because my inbox is too full' and want you to stop by their office," says DeCaporale-Ryan.
3. Build relationships
Get to know your colleagues, advises Kathleen Ashton, PhD, a psychologist in the Cleveland Clinic's Breast Center and an associate professor of surgery at the Cleveland Clinic Lerner College of Medicine. While email via an EHR system is fine for routine consultations and updates, personal connections help strengthen the team and thus improve patient care. "If I'm in the oncology or surgery clinic and I've seen someone's patient, instead of just sending an electronic note, I'm going to tell them in person and say how that person is doing and ask if there's anything else I can do," she says. She'll also pick up the phone instead of sending an email, especially when cases are more complicated.
"Lunch and learn" sessions and continuing education on topics of common interest are another way to come together personally and professionally, suggests Anne E. Pidano, PhD, an associate professor of psychology at the University of Hartford, and colleagues (Journal of Clinical Psychology in Medical Settings, online first publication, 2018).
Also, be sure to get out of your office and mingle, emphasizes McDaniel. Sometimes psychologists new to integrated care will sit in their offices and wait for clinicians to contact them. "Waiting for an engraved invitation won't work," she says. Instead, get out into the suite, interact with staff and patients and make yourself available for consultation.
4. Mind the basics
Patients in medical settings may already be feeling vulnerable and need extra kindness, says Protocol School of Ottawa Director Suzanne Nourse, who trains health-care professionals on the fine points of etiquette. "The patient may have their gown flapping open at the back, they're already scared, they don't understand what's going on and things are beeping," she says. "The key is to make people feel more comfortable and respected." That means knocking before entering a patient room, smiling, talking slowly and maintaining eye contact with patients, says Nourse. If you have your own office space in the practice, rearrange the room so that the computer where you're taking notes isn't a barrier between you and your patient.
And don't be a "Doctor Doorknob," talking with a patient with your hand on the door as if you can't wait to rush to the next patient, Nourse says. Even something as simple as sitting down next to a patient's bed can improve patient satisfaction, even if you don't spend any more time than you would standing up, according to a study of physicians at an academic medical center (Journal of Hospital Medicine, Vol. 11, No. 12, 2016).
Because patients there for physical conditions may not be expecting to see a psychologist, introductions by physicians may downplay official titles. "We tend to say they're a behavioral health consultant or a specialist in helping you sleep or helping you with weight loss; sometimes we say they're a coach," says Diana L. Heiman, MD, who directs the family medicine residency program at East Tennessee State.
Once people understand that you're a psychologist, they may expect traditional 50-minute psychotherapy sessions, so it's important to clarify expectations when you introduce yourself, says Polaha. She tells patients up front that she usually meets with people for 15 to 20 minutes to learn about their problems and see if there are ways she can help. "That gives them the sense that this isn't traditional psychotherapy," she says.
Polaha also tries to see patients in the same exam room where they've seen their physicians, which helps patients understand their psychological care will be delivered the same way primary care is—briefly and with possible interruptions. Another provider may pull the psychologist out of the room for a brief consult or introduction to another patient, something Polaha handles by giving the first patient a quick assignment, such as listing values important to him or her, to work on until she returns.
5. Pick up your pace
Medical systems are typically fast-paced environments, with emergency rooms at the busiest end of the spectrum, says Jennifer M. Peltzer-Jones, PsyD, RN, a former nurse who's now the senior staff psychologist in the emergency department at Detroit's Henry Ford Health System.
With colleagues, she suggests, keep your reports brief and to the point. While psychologists often delve into patients' histories, physicians typically aren't interested in the details unless they are related to the medical decision at hand, says Peltzer-Jones. "The No. 1 thing is to really understand what a physician is looking for when they engage your assistance," says Peltzer-Jones. Usually that means a quick summary of the patient's condition, the treatment plan and recommendations for other clinicians.
And don't waste time by competing with other psychologists on your team, says Ashton. "If there's more than one on a team, sometimes they feel they both have to say something in every situation," she says. "Recognize that if your team member says something, you don't necessarily have to elaborate."
6. Be aware of new challenges related to confidentiality
Unlike private practices where privacy is guaranteed, hospitals and other health-care settings are often crowded. There may be another patient on the other side of a curtain, for example. Or your patient may have family or friends visiting. When there's someone else in the room, you have to create your own privacy, says Linton. If a patient with a roommate is ambulatory, for instance, you could take him to a nurse's conference room. Or you could ask visitors to step out for coffee for a few minutes. If visitors have traveled a long way and visiting hours are short, you can come back later.
It's also crucial to be transparent with patients about what you will and won't share with other team members, says Ruddy, who invites patients to "co-create" what goes in the chart. She might ask patients how they would tell their physicians about what they discussed with her, for instance. "If a patient doesn't mention something really salient in the conversation, it's really important to say, ‘I notice you didn't mention that your husband has become physical to the point that you're pretty scared of him; it's important for the doctor to know that, but obviously I respect your privacy,'" says Ruddy. You can then negotiate with the patient about what gets shared, perhaps by classifying a stigmatized problem such as domestic violence as "family stress," for example.
And don't hold information back from your team members once patients have given you permission to share it, adds Ruddy. Psychologists, she says, "tend to be almost secretive about what people tell us," but shared information is at the core of integrated care. "Don't assume that your relationship with the patient is more ‘special' than the relationship between the patient and the medical provider," says Ruddy.
7. Know the boundaries
In medical settings, psychologists may cross boundaries that psychologists in other settings would consider off limits, says Jeanne S. Hoffman, PhD, chief of the pediatric psychology clinic at Tripler Army Medical Center in Honolulu. While most psychologists avoid touching patients, for example, a psychologist in a hospital setting might hold a dying patient's hand or even suction a paralyzed patient's saliva during therapy. And while many psychologists don't attend patients' funerals, when a patient dies, Hoffman is right there next to the physician and nurse team members to support the family.
Psychologists in integrated health-care settings may also see patients exposed. When a child panics at the thought of bowel imaging but can't be sedated, for instance, Hoffman might be there to help keep the patient calm. As long as such boundary crossings are in a patient's best interest, it's OK to deviate from standard practice, say Hoffman and co-author Gerald P. Koocher, PhD, of DePaul University (Practice Innovations, Vol. 3, No. 1, 2018). In the case of a child undergoing bowel imaging, for example, Hoffman's presence means that a necessary procedure can be completed. As long as the action is for the patient's benefit—and no one else can do it—it's acceptable, says Hoffman. If a patient needed an escort to the bathroom or was vomiting, she adds, "there's someone else to do that" so psychologists should call a nurse instead of taking on the task themselves.
What's not OK, says Hoffman, are the personal consultations physicians often find perfectly acceptable. "That's part of the culture: They'll say, ‘Hey, take a look at this' or ‘I've been coughing up that.'" It's fine to provide resources or referrals, says Hoffman, but getting too deep into personal troubles is a boundary violation. That means quick advice on a very defined problem, like a child's toilet-training issues, are fine, but a colleague who wants to share his marital troubles should be referred to another provider. "You have to think how something will affect your relationship with the other person," says Hoffman.
8. Earn, and offer, respect
Health-care settings have pecking orders, and psychologists may have to assert themselves if they work in a setting where they are vastly outnumbered and sometimes underappreciated, says Linton. "Not everyone is going to appreciate what you do," says Linton, whose own facility employs 800 physicians and just 16 psychologists. While the new generation of physicians has often trained alongside psychologists and understands the value they bring to the team, he says, senior physicians who aren't as familiar with working with psychologists sometimes act in a disparaging or disrespectful way toward them. Even the fact that psychologists are called "doctors" when they're not MDs can grate on some physicians. Change their view by showing how you solve problems with your shared patients, says Linton. "That tends to have a halo effect and make [physicians] see you in a different light," he says.
Also, be a generous team member by acknowledging colleagues' expertise and accomplishments. "I really try to see when my team members are doing a good job and let them and the rest of the team know," says Ashton. When a patient told Ashton how amazing her surgeon was, for instance, she passed the compliment on to the surgeon and her bosses. When someone's a good team member, Ashton says, it not only makes her job easier but also helps fulfill the potential of integrated care.
Professional Etiquette for the Integrated Care Psychologist
Ashton, K., 2017
My Lessons Learned in Integrated Primary Care
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