Graduate Medical Education,
Andrea Bigler, program manager of the Mixed Methods Research Lab interviewed the Wright Center's President Dr. Linda Thomas-Hemak, Dr. Meaghan Ruddy - Director of Medical Education and Scott Constantini - Director of Behavioral Health Services.
The Wright Center is a non-profit, community-based graduate medical education consortium and safety-net provider of primary care services with a mission to continuously improve education and patient care in a collaborative spirit to enhance outcomes, access and affordability.
The organization was founded in 1976 as an Internal Medicine residency program and has blossomed into a robust, nationally-recognized Graduate Medical Education Safety-Net Consortium (GME-SNC), serving 17,500+ patients annually and training 200+ learners within community venues across America.
The Wright Center’s team aims to develop culturally competent doctors and integrate mental health, dental services and other specialty services into primary care for a whole-patient approach to care. At the heart of all that the organization does is a strong commitment to graduate medical education, patient and family care and positive regional impact, inclusive of community service and economic growth and development.
Andrea Bilger : Thank you for taking the time to speak with us today. I'd like to start by asking what do you think are the emerging educational issues for training primary care providers in integrate and behavioral health?
Linda Thomas: One of the first emerging educational messages is regardless of what you build and how you invest in continuing education, there is a cultural deconstruction that needs to happen, because primary care has been doing variable scope of behavioral health without a well- developed infrastructure for a long time. The nature of primary care is such that a significant proportion of the population which shows up for physical primary care services actually present with a behavioral health complaint or have an underlying behavioral health component to their current medical and physical health challenges. I think what’s emerged is a pattern of reactive skillsets that emerged responsively to patients’ needs without formal curriculum and often without actually learning or appreciating the science of behavioral health, addiction, and recovery.
Andrea Bilger: When you said that a cultural deconstruction needs to happen. Could you elaborate?
Linda Thomas: We need organizations to present the vision and framework of what it means to truly integrate behavioral, physical, and oral health services. We’re going towards comprehensive primary care delivery and the doctors need to realize that a large component of the services that they have been providing in primary care are behavioral health services.
As part of a well-constructed, integrated comprehensive care model, they need to identify the level of their previous engagement in behavioral health services because they need to understand that the scope of care is expanding to something much bigger and perhaps more evidence-based than what they’ve done for individual patients over 10-20 years. Advancing primary care provider teams’ evidence-based and collective behavioral health skillsets will be an awesome outcome if the cultural transformation is strategic and intentionally implemented with historical sensitivity to past experiences.
Primary care providers also need to recognize their successful engagement in promoting and guiding health risk screening, managing depression and anxiety, and supporting people with chronic disease is linked to behavioral health, addiction and recovery.
In reality, efforts at integration bring on significant challenges in the financial, business, and health industry space. If we don’t go to those conversations with an understanding of the purpose and need for integration, these early efforts may be stifled and leadership of these efforts may get discouraged. Those barriers are really challenging and sometimes appear insurmountable. Purpose keeps us hopeful and energized for change.
Scott Constantini: I worked in behavioral health for 20 some years. It’s exciting and it brings joy to my job to know we’re trying to integrate with primary care. One of the other challenges that we face all the time is there are a lot of barriers within our own system and in our own space. “Who is going to pay for that licensed clinical social worker to be down in medical?”. Do we just continue to say, “It’ll go under the doctor?”. At the Wright Center, we do the right thing and we make it work, that’s one thing I respect about Dr. Thomas. She’ll make it work whether it has to go under the doctor, or we find a grant, or we find resources through somebody or an agency that is an integrated behavioral health champion. At the end of the day, that social worker is really saving the insurance company’s money by keeping them out of an ER. Collectively, we need solutions and both government and insurance companies to help our provider community sustain an integrative model that we know works.
Andrea Bilger: What do you all think are the most pressing challenges? We talked about educational issues in general for IBH but what do you think are the most pressing challenges for educational programs? What seems to be the biggest barrier in training and education?
Linda Thomas: I’ll start from the current workforce who’s actually delivering the care. When things like the MAT certification come out, there’s obviously a time capacity issue in primary care. That’s only eight hours, but then there’s also two hours of child abuse, hours of risk management, CME activities, board certification and on and on. There’s a lot that drains the capacity of practicing care teams. I personally think that one of the greatest challenges is the capacity to invest in educating and developing the skills of the workforce that is currently providing care in the care delivery system.
We have to figure out how we generate a learning culture where we work and care for patients every day. We need to both generate the capacity within the work we do every day as well as change the culture to one of learning. We need an open and free culture where people have the ability to express what they need and to cogenerate solutions. We need to ask staff more often “What do you need to take care of that patient and family?”. The challenge is the way that the resources are managed and the fiduciary intermediaries of the insurance companies often are missing this perspective.
Meaghan Ruddy: I think part of it is curricular overload. In medical school, the curriculum’s been additive for decades. Where do you put it? If you put it in the first two years, it gets lost because it’s not on the USMLE Step exams. I’ve had that experience personally, being brought in to teach human development and ethics and just being ripped apart by medical students who just want to know what they need to know to get the highest possible score on the Step exams, so that their residency options stay open.
If you wait to put it in the third year, then you come up against the issue that Linda was just talking about, where you need to have the capacity already built in to the clinical preceptors and clinical faculty.They’re already busy and they’re already overwhelmed and there’s a capacity issue. If you allow for it to be experienced through electives or selectives then only the people who are selecting in are the people already interested. Then if you put it in residency, residency is one of the busiest times of the career transformation of a physician. Again, you’re faced with the capacity problem of the faculty. For me, where to put it in such a way that it actually makes a difference is probably the most pressing challenge.
We’re lucky in that we work with a lot of FQHCs across the country who are investing in IBH in their own ways. In an FQHC they’re incentivized to do IBH because of the way they’re set up. There needs to be a whole industry conversation. The National Academy of Medicine has been identifying the need for IBH for a couple of decades and we’re still struggling working through the challenges of implementation.
Andrea Bilger: What would you say is the most promising innovation in integrated behavioral health training that has caught your attention?
Linda Thomas: The most promising innovation in this whole journey is the engagement of patients and families, bringing their capacity to the conversation to help us rethink and redesign care. I think one of the greatest concordant innovations is in the world of IT, where patients and families can use electronic health record portals to directly share their stories, socio-economic determinates of health, and the challenges and the barriers that are driving care gaps or addiction.
Scott Constantini: What I really like in integration is addressing an issue in the here and now. A patient comes in today, is experiencing depression, and we can get a social worker involved to help them and guide them immediately. Another one is around substance abuse. Having an MAT program and platform embedded in primary care, I honestly feel, is the future and a solution to really put a dent in the opioid crisis.
Even from a behavioral health standpoint, we have people come into our department who are not being seen by the primary care providers. When they come into behavioral health and they’re in a session and having a lot of issues around physical health, immediately linking them with our physical health department is very powerful. I believe that integration is the future. I’m excited about being a part of changing the way we deliver behavioral health and coming up with a collaborative care model that will work and that we can sustain in the future.
Linda Thomas: If we take people outside their comfort zone into the future of better care delivery, we have got to give them the space to have the conversations and to reflect on how it’s going and what went right. Because we bring very different frames of reference, we need to allow brainstorming and the opportunity to ask "What worked and what didn't?".
Meaghan Ruddy: There is a lot of potential in health IT to create some of those bridges where there are currently barriers. Also, the Family Medicine Review Committee and the ACGME just allowed, beginning July 2019, for non-physicians to be considered core faculty members in family medicine residencies, which opens up a whole door to not only behavioral health but other mid-level providers and care teams.
To me, that goes hand in hand with the Teaching Health Center GME in which the Wright Center is deeply vested. That was a huge door opener to training primary care residents in community classrooms. Creating learning environments in these places can inspire and even force some of those hands to get the integration that they need to meet the education requirements. In this way, the education requirements can actually be the driver and catalyst. It’s great to see that happening.
Andrea Bilger: Is there anything else that you would like to share in general that we have not gone over yet?
Meaghan Ruddy: There’s a lot of different pieces of this to keep in mind. Healthcare culture needs to change but it starts with each individual clinic with each individual member of each individual team. It requires working together to create learning organizations in every clinic that will inform the care delivery system at local and national levels. We can start small and don’t have to accomplish it all at once.