I believe many physicians in primary care are troubled practicing in the current healthcare environment. Regardless of what they earn, many feel they are too busy and don’t have time to adequately listen to the concerns of their patients and their families.
A recent article in the Boston Globe titled “The precarious future of primary care” echoed those sentiments.
In contrast, I have spent a lifetime finding ways of doing good for others, earning a reasonable living, and loving my work as a pediatrician, so I feel very differently. I want to be helpful for my colleagues in primary care.
I grew up in a troubled family with physical and emotional problems. When I was 4 years old, my father, having Crohn’s disease, needed to have much of his small intestine removed. He expected to die every year thereafter, but didn’t until years later—from Alzheimer’s disease. Family members were depressed because of his illness and chronic disability.
In medical school, I chose to be a pediatrician. I became motivated to learn about mental illness in families, becoming a solo practitioner with that focus. I became competent doing so and would have continued this kind of practice. However, 2 experiences intervened.
In 1995, I participated in the Bright Futures program. It provided time for me to learn more about understanding why families develop emotional problems. In 1998, I became aware of the problem of domestic violence, and 2 years later, with a colleague, I wrote an educational guide for pediatricians.
I developed an educational website, downloading the domestic violence guide as well as other topics relating to emotional problems of families. One of our supporters encouraged me to develop a training program for pediatricians based upon my practice experience. I did so but without long-range plans. The first 2 training programs were somewhat successful.
I decided to pull together everything I had learned during my years of practice as well as my experience teaching others how to become similarly competent, but I still had a problem. Even after 2 programs I had no clear vision how to proceed. Although I worked closely with colleagues, for some reason I chose to lead our program without being particularly dependent upon others for advice.
At the same time, however, I developed a professional relationship with a parenting educator. We met on a professional LISTSERV, but did not meet in person for 2 years. We shared much information about our respective histories. One day, we were given the opportunity to discuss our collaborative process at a national mental health meeting. I had never been so open before. Learning to depend, but appropriately, upon a new colleague helped me become a better role model for those I trained. I began to realize that our program of training pediatricians was developing a unique way of integrating mental health with primary care. I ended up modifying and improving our program.
How CEHL came to be
What training program might you consider when looking for one that will enhance your pediatric skills, your self-esteem, and your professional satisfaction? I would recommend Children’s Emotional Health Link (CEHL), an innovative physician-patient communication model and training program for the psychosocial care of children.
Our CEHL program began with luck, curiosity, and support from a friend. One day in 1998, I passed by a room in the hospital used for teaching. Female employees were consoling one another after a colleague had been murdered by a former boyfriend. I sat and listened, and met Melinda Strauss, the leader of my hospital’s domestic violence program.
A friend and teacher, she educated me about this problem. We collaborated on a booklet titled “Routine screening for domestic violence in pediatric practice.” I asked Blue Cross Blue Shield if it would distribute the booklet to primary care physicians, and it agreed. We later downloaded the booklet to a website. Melinda and I gradually added other topics to the website, now known as www.cehl.org. I developed a program to train other professionals. It was my hope that what took me 30 years to learn, other professionals might accomplish in 1 year.
Beginning in 2002, we embarked on a remarkable 12-year period. We developed a unique course, and 4 separate 1-year training programs took place over time. The early years were challenging, however.
We decided to reassess our third program in 2009. We kept some features including a yearlong training program. We chose to have 15 participants and dinner preceding our evening program. We developed a workbook, and although we didn’t focus on psychopharmacology, we updated that part of our website yearly. From having only pediatricians, we added nurse practitioners, school nurses, and medical specialists. We lengthened our monthly program. Instead of psychiatrists, we chose to have pediatricians teaching pediatricians and, at the same time, we enriched our once-a-month didactic training.
We insisted participants present their case histories as supervised process recordings, downloading them to a secure website. With many risk-management credits available, we called upon the other participants to contribute comments to our secure site. We gave stipends until 2011, but then began to require tuition. By raising expectations for our participants, we somehow motivated them to work harder with their patient families.
Julia Swartz, a co-director, developed a resource book for participants. Our other director, Beth Rider, added the “Program to enhance relational and communication skills,” a workshop focused on difficult conversations in emotional illness that made use of actors.
What was our outcome in 2011 and 2014? The feedback we received from participant evaluations was perfect. We are now at the top of our game. The rest is history.
Integrate mental health care with primary care
Beginning with participation in the Bright Futures program in 1995 and over time, I gradually formulated principles to facilitate my success as a psychosocial pediatrician. These principles also began to facilitate success for the participants in our last 2 CEHL training courses.
These 15 principles ask:
Are you aware of the importance of . . .
The role trust can play in how you interact with families and co-professionals? You depend upon the reliability of patients’ histories so you require their trust. Similarly, when communicating with colleagues, don’t be reluctant expressing your true feelings.
The role of time when taking histories from your patients? By asking parents to return for an hour-long visit, you will be able to clarify what is going on within the family system. In addition, time spent even during well-child visits may disclose useful clues worth investigating further.
Viewing family members as “agents of change”? You’re not interested just in modifying the behavior of your patients, but also in understanding how they help you impact other family members. There aren’t enough professionals working on behalf of change. Working with parents can help you improve the emotional health of others.
The role of empowerment in parents with whom you work? Parents can be allies in the service of change. They can play an active and informed role, but we often overlook calling upon them to do so. Help parents become better decision makers so they can help you achieve your healthcare goals.
The length of the training program when seeking real change? Learning to be comfortable with mental health concepts can’t be mastered in a short time. When trying to change habits, it takes time to learn. Our course is 36 hours long.
The role of curiosity in interviewing family members? You need to be an active listener. It is also important to learn to listen for associations; ie, how “ideas” can be unconsciously and meaningfully strung together in conversations with adolescents and, particularly, parents.
Process recordings? They are a unique way of taking clinical histories. You are thorough not only in how you record parents’ answers but also in how you record the affect in their responses. You will be asked, “What were they feeling at the time?” You will discover useful information by addressing these questions.
The need for a secure website? When the history you have obtained is presented to your peers, it is downloaded to such a site. Your colleagues are then asked to share their responses. At that time, anticipate a robust discussion with your peers regarding the details of your recorded history.
A “circle of trust”? That is what takes place in such discussions. There is amazing openness and trust as the group collaborates in the problem-solving process.
Asking “Who is the real patient?” Parents usually believe it is the child. More often, it is the parent. Family histories often disclose that parents have been impacted by depression, alcoholism, or abuse in their own parents. In short, the “real patient” might well be the 3-generational family system.
Family secrets? Whenever there is a problem in the child, there usually coexists a family secret. These secrets account for how the child became the “identified patient” in the family. Sometimes there is a family history of alcoholism. The impact of that secret is often transmitted through generations.
Psychopharmacology update with each program? Our course focuses on listening and understanding as opposed to psychopharmacology. Our goal is for you and your colleagues to make your own decisions, so you deserve up-to-date data.
The composition of your training group? We believe the more diverse it is (eg, physicians, nurse practitioners, school nurses), the richer the discussion will be.
Evaluations after each program? Rich discussions often predispose to good self-criticism. Still, good evaluations bring about quality outcomes and respect.
Professional satisfaction? In that case, consider being part of a program that embraces these qualities. Similarly, if you strive to achieve these qualities, you are more likely to achieve professional satisfaction. The same can be said regarding the best way to avoid professional burnout.
Incidentally, there are many who enjoy professional satisfaction by employing a co-located mental health professional. Speaking only for myself, I wouldn’t want to give up what is for me the most important and satisfying part of my professional work.
For more information on the Children’s Emotional Health Link (CEHL) and its programs, e-mail Dr. King at [email protected]
Dr King, a board-certified pediatrician, is founder and director of the Children’s Emotional Health Link and honorary member of the medical staff at Newton-Wellesley Hospital, Newton Lower Falls, Massachusetts.