Roles of the Behaviorist in Primary Care Practice

Dr. Brian McDonough:
Welcome to Primary Care Today on ReachMD. I'm your host, Dr. Brian McDonough and with me today is Dr. Janelle Von Bargen. Dr. Von Bargen is a behaviorist in a family practice residency program so she sees what many of us in primary care have seen at the early stages, the middle stages, late stages because she deals with residents and faculty and medical students.

I guess my first question, because I don't remember necessary working with a behaviorist when I was a resident way back, what does a behaviorist do and what is their role in a primary care family practice training program setting? And then we'll move from there.

Dr. Janelle Von Bargen:
The best thing about the behaviorist position is it really takes on the personality of the behaviorist and every individual program, but our primary responsibilities are to provide support for residents in their ability to not only understand but learn how to incorporate addressing psychosocial issues with patients, and really helping the patient make their own treatment plan based on their lifestyle needs, and that's something as many physicians deal with every day also struggle with understanding the challenges that our patients face every day in their lives.

Dr. Brian McDonough:
So essentially what you're trying to do, from what it sounds like, is you're helping young doctors try to figure out, maybe almost to get outside of themselves and help others and try to figure out where those patients are.

Dr. Janelle Von Bargen:
Absolutely. And it's hard for many of us when we don't live those daily lives or understand the struggles that a single mom is going through and a patient who has been laid off and is trying to get back to work but has to deal with the healthcare system and as a result the doctor ultimately gets the blunt of that frustration from a patient, and for many doctors that's a challenge and frustration because they're trying to help the patient when in reality the healthcare system is kind of pulling the rug out from underneath them.

Dr. Brian McDonough:
Well you know, you're getting into something which I know a lot of our listeners...and by the way, we have resident listeners, listeners who are in practice, non-physician listeners for that matter, but for the physician group in primary care you're getting into something which is a tough issue right now which is the changing healthcare system. I mean even if you were raised in one form with one idea and you were making it work for a bunch of years things are changing so rapidly economically. They're changing from the standpoint of practice patterns, how patients perceive their physicians, how hospitals work with physicians. There's so many changes. How do you help the doctors in dealing with their patients in this kind of environment?

Dr. Janelle Von Bargen:
Well I think one of the biggest issues that our doctors face is not knowing where the patient is coming from. Some of our patients come in and are very informed about what they perceive to be the best treatment because of technology today, because of what they've heard from a relative or a loved one, and so our doctors have to listen to where the patient is coming from and many times there are so many sources of information now about what might be causing this pain and by the time you get to the bottom of where the patient is at you've already spent your 15 minutes with that patient, and so it's very frustrating for doctors when they have to see four to six patients an hour and they're not able to have those conversations with a patient because they have to see more and more patients every day. That's a huge challenge for the residents to be able to have good time management and still provide quality care to their patients.

Dr. Brian McDonough:
Most of us remember and probably deal with a regular basis those same things you're talking about. The struggle of trying to get through and find that quality care. So how exactly do you help them? I mean, you hear the complaint, it's not possible especially for a resident. You expect me to see four people, five people in an hour? I can barely get through two. How do you get them to not really just get totally distressed, frustrated, angry, all those things?

Dr. Janelle Von Bargen:
Well the reality is they do get totally distressed and angry, and the bottom line is it's a skill that's learned and it's something that what I perceive as you kind of go back to the old medicine of listening to the patient. If most of the time we let someone talk and tell their story, they can do it in about two to three minutes, but unfortunately because doctors are feeling so pressed for time they will interrupt and ask questions and then the story will go a different direction. Especially with a first year resident we might start out just thinking about agenda setting with a patient, what are the two things you want to talk about today and that's all they're going to talk about.

Another thing that's real important is that the general population doesn't know that they only have a 15 minute visit with their doctor and so people come in with a list of issues they want to address in their one appointment in six months, and so I think on the role of the doctor it's important that we better educate our patients on the expectation of the visit. Today we might only be able to talk about these two things so we need to talk about what's most important to you. And the doctor has to make a judgment there. If it's a life-threatening issue of course you have to address that issue but if there's an issue that the patient really feels is most important they're going to leave much more satisfied if they feel their issues were addressed, too, and then bring the patient back. You know and you have to be mindful of that as well, is this patient likely to come back or not? But if they feel and all the research shows, if a patient feels the doctor hears them they trust the doctor, and so allowing the patient to feel heard will allow the patient to want to come back for that second or third consultation in a three month period.

Dr. Brian McDonough:
If you're just tuning in you're listening to Primary Care Today on ReachMD. I'm Dr. Brian McDonough, your host. I'm speaking with Dr. Janelle Von Bargen, she's a behaviorist in a residency program and we're shifting a little bit from the concept of residency programs and working with the residents to probably working with all of us in one extent or another, and we're talking about the challenges in healthcare and right now the particular challenge is time and how to do what you need to do in a short amount of time. What about the beginning and many of us are even beyond that in practices, the emergence of the EMR, the fact that doctors are now in rooms and they're clicking on their laptops or computer-based terminals or wherever, but trying to maintain some sort of conversation with the patient, trying to have eye contact and at the same time typing and jumping through a bunch of hoops that perhaps others have put upon them?

Dr. Janelle Von Bargen:
Absolutely. You know and I think you have to be mindful of who your patient is and at a certain age there are people that have never been in a room without a computer, and then there are those patients that are still a little offended by it. So I think it's important for the doctor to just be cognizant of the type of patient they're working with. As I work with my doctors and say, introduce the computer, show them the screen, hey, while we're talking, I've got to keep this file up to date so if someone else sees you, if I'm not here the next time everything we talk about is in here. So I'm going to listen and take breaks but kind of introduce the computer as part of the visit, and I'm sure many of us have been in doctor visits where you forget that it's even there, where other times there are times that a doctor doesn't make a lot of eye contact. Again, a patient is going to walk out not feeling real satisfied if they haven't had that doctor turn to them and give them really face to face and eye to eye contact. So that's important. That's the first thing we do.

But I also just observed one of my doctors with three generations in the room with the doctor, all three generations had some type of device. There was a four-year-old kid that had an iPod and the grandmother in the room was playing a game on her phone while the second generation parent was actually the patient and she was playing on an iPad, and I just found it very interesting that there were four different electronic devices in the room which can also be distracting for the doctor when a patient gets a phone call during the middle of a visit which happens often as well, and so I think it's about laying ground rules and having an expectation as we've got 15 minutes, let's use it wisely and this is how I'm going to use the computer to help facilitate this visit.

Dr. Brian McDonough:
And you do all of this things and you bring these steps and obviously some physicians have more structure, more success, more happiness than others, and some remain disappointed. What to you give the person who you've tried all these things, you know, and you're really working with them and they just don't seem to be turning that corner, what can you do to help them at that point?

Dr. Janelle Von Bargen:
Well again, I think a lot of it is who is struggling with what. Is it a time management issue? Everybody does what they're comfortable with. There are some doctors that are more comfortable not using the computer in the visit and then allowing for five minutes after the visit to go and sit down and write your notes. We have some doctors who wait until the end of the four hour shift to log in their notes for all of their patients that morning, and if that works that just may be what they have to do. The biggest issue is really allowing the patient to know that you're providing good care and there are some doctors who use that computer and you don't even know it's there. I mean, it is a skill and it takes time and I think sometimes you might be more uncomfortable than the patient actually is. So it's really trying to figure out what works best for you and the patient.

Dr. Brian McDonough:
Looking into the future a bit, what do you see the future of medicine with perhaps even more time constraints if that's possible and more frustration, how do you see it changing for the better for the patients? Because clearly as a behaviorist that is your biggest focus.

Dr. Janelle Von Bargen:
If the time constraints become worse it won't be better. It can't be better for a patient. I mean, we see it every day, patients who come in who just want somebody to hear their complaint and we've gotten away from having that luxury. So I think for a patient it will be detrimental if the visit has to become shorter and for the doctor, as some of the research would lead us to believe, burnout is a huge issue and this is a big precursor to it that the doctors are not feeling satisfied with their relationship with their patients because of these time constraints which ultimately leads to burnout. With burnout the doctors are feeling depersonalized because they're not getting gratification. They're feeling a sense of this isn't what I went into medicine for. So I think there's going to be some pushback that it can't become a bigger constraint. Other than all doctors walking around with an iPad and we start scanning people and their charts automatically come up, but I don't think we ever really want to get to that level of depersonalization, either.

Dr. Brian McDonough:
Is it going to get to that point? Is it going to get to the point where doctors just say well listen, I'm here for eight hours, I am going to fill in the boxes that I'm told to fill in, nothing more nothing less, and just not even get frustrated about it because after all that's what they expect and they're not paying what they used to, you know, just kind of a more of a passive aggressive, negative, that's what it is, that's what they get attitude? Do you see that happening?

Dr. Janelle Von Bargen:
You know, I sure hope not and I don't think it will because I do believe that's when mistakes are going to happen. If we don't have time to listen to a patient and understand what's going on, I mean more of time if you sit down with a patient and you get their first symptom of their problem, that's the first symptom and then by the time you've heard the third one now you have a better picture as to what's going on, and if we get away from that we're really putting the safety of our patients at risk. No one wants that to happen and/or the liability for that to happen. So I really don't think...and hopefully it won't take a catastrophic event of a series of events to occur before we realize we're going in the wrong direction with this.

Dr. Brian McDonough:
I'm talking to Dr. Janelle Von Bargen. Is there anything with an audience like this, primary care doctors around the country and actually more than just the country, around the world, that you think you'd like to get across to either help them or try to deal with them in a way so they can help their patients more?

Dr. Janelle Von Bargen:
I think it's important that doctors stay up to date to what their patients know, who their population is, are people using different sources of the media, and what is that? You know, how can you reach out to your patients a little better? As well as taking time to self-reflect. We know that it's important for doctors to reflect on their emotional reactions to things and again, in order to help prevent burnout and to keep people fresh. If we're not able to do that then we're not going to be in our best mode. You and I both want to see a doctor who's in good shape and who's ready to provide me the best care. So I think it's important that people are comfortable in the time that they have with their patient, use it wisely, and if they need to learn new skills, you know, there's so much on the internet now where you can take a class and learn how to better use the computer in your visit or take crib notes so you're able to do things more efficiently, and that may be what people need to do.

Dr. Brian McDonough:
As you look at these things and work on those things obviously you're going to be training the young doctors, do you see hope for the future? Do you see it as something optimistic that it is getting better? What's your take on young physicians, where they are and is it a positive trend?

Dr. Janelle Von Bargen:
Well I think the reality is for young physicians after the generation we're currently in, they won't ever know a time without a cell phone or a computer and so they're very tech-savvy and they can get to the point where they can dictate in two seconds and do it on their phone. As long as that patient is feeling listened to and we're treating what they need people are going to be happy.

Dr. Brian McDonough:
Well Dr. Janelle Von Bargen, I want to thank you for taking the time to join us on Primary Care Today on ReachMD and I want to thank you for all the insight you provided. It's been a very interesting program. In case you have only caught part of this program or you want to hear it again, realize that you can visit ReachMD.com/primarycaretoday to download the podcast and learn more about the entire series. I'm Dr. Brian McDonough. Once again, thank you to Dr. Von Bargen and thank you for listening.