“One Year in Primary Care”
July 1, 2004
As a newly licensed psychologist specializing in child psychology and psychopharmacology, I was happy to accept an invitation to work part-time in the office of a family practice doctor in rural California. Looking back on my first day in October of 2002, I now realize the enormity of information that I had to learn and assimilate to work effectively in such a new and fast-paced setting. I anticipated that I would need to learn a lot of new skills, but was completely unaware at the time that those new skills would be primarily procedural and ethical/legal, as opposed to clinical or medical.
Months of preparation prior to my first patient, included creating specialized informed consent forms, release forms, and all the normal psycho-legal paperwork. However, I was wholly unprepared for what I soon learned would be the majority of my work. Instead of one or two visits to establish consent and relationship, followed by four or five visits to get a diagnostic impression and a treatment plan for determination of further treatment, I was asked to do brief psychological triage, one visit diagnostic and medication consultations, and somehow document this all in a legal and ethical manner! I vividly remember persevering on my decisions of the day during my three-hour drive home. This continued for the first four to five months in this new role, and I was often left realizing I could have done better.
Raised in a rural town myself, I should have been aware of my next major dilemma. However, training in big towns had made me forget that referrals are not always as easy as signing a piece of paper or making a phone call. After many successful brief interventions, I finally saw a patient who needed a referral to a psychiatrist and maybe a neurologist. I wrote the referral requests to the primary care physician and went on my way. I later noted that the patient in question was seeing me again, and I saw no mention of either referral. I was kindly informed that the family practice M.D. and I were the psychiatrists and neurologists, as there were no REAL specialists to refer to –they did not exist in that area. I was reminded of the plight of family docs in the western themed television shows of my childhood. In much the same way we had to do the best we could with what we had.
There were many learning experiences that first year. I have had to acquire competence in child custody, neuropsychology, testing, behavioral medicine and health psychology, neurology, and even some psychoneuroendocrinology in a short period of time. However, the most demanding aspect of the job was figuring out how I was going to follow my legal and ethical codes in a professional manner when none of those codes were written to apply to primary care psychology.
There are many pointers I could give for someone considering such an endeavor, but I only have room here for some essentials. A good office manager is essential. You will not have time for scheduling, organizing files and making phone calls in primary care. Stay fee-for-service. I am only an approved provider for one insurance company, and only did that for the benefit of a very needy patient who could not afford to pay. You will not have time to do billing, and medical billing services can be a large chunk of your reimbursement. Study your demographics well. Know what professionals are available for referral, learn about the culture of the area (especially if it is rural) and make a point to know the town, its streets, schools and churches if at all possible. Lastly, be flexible. You will need to be ready for anything because over time you will see it. Being a strict behaviorist, Freudian, or whatever will not serve you or your patients well.
My first year in primary care was hard, but the struggles were well worth it. I have seen hundreds of different patients from several surrounding counties, and the work is as exciting and varied as it was on my first day.
Scott Wylie, Ph.D., is a clinical psychologist on staff at Sonoma Developmental Center in Eldridge Calif., and in primary care private practice in the Sierra foothills of California. His e-mail address is: firstname.lastname@example.org
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