Jeffrey L. Goodie

The Right Book at the Right Time

Perhaps the best way to summarize the new book from Christopher Hunter, Jeff Goodie, Mark Oordt, and Anne Dobmeyer, Integrated Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and Intervention, is to label it the right book at the right time. This important addition to the growing library of primary care behavioral health (PCBH) texts does more than inform and assist those mental health professionals working in primary care. It also, by its very nature, represents the evolution of the PCBH field.

The Train Wreck: Assessment and Management of a Complex Medical Patient

The difficult patient, like the illustrative train wreck about to be described, is a complex dilemma not infrequently confronted by physicians in the clinical setting. These patients come in many versions but typically involve complicated medical histories, extensive medication lists, and repeated medical visits without any apparent medical benefit. The patients do not always seem to want to get well and physicians are frequently unsure what to do to make them better, leading to ineffective care. Recurrent, vague complaints such as insomnia, back pain, dizziness, fatigue, or abdominal pain are superimposed on known medical conditions that are typically suboptimally treated. The pursuit of diagnoses to explain somatic complaints can distract from the care of other chronic conditions, adding frustration to the encounter. Clinical time constraints, productivity demands, and a desire to cure further result in conflicting expectations between the patient and the physician. In spite of a commitment to care, the physician working with a difficult patient may feel guilty when his or her efforts to treat a patient appear to be failing. Unsure of where to start or what to treat, the individual physician begins to experience a sense of helplessness, not so dissimilar from distress experienced by the patients themselves. A clinical health psychologist is a strong ally of the physician in caring for these challenging patients. Since unrecognized psychiatric problems often lead to high health care system utilization and vague medical complaints, health psychologists have added expertise in identifying these issues. Less confined by the time constraints of a 15-min encounter and separated from the pressures of treating concomitant health conditions, health psychologists may accomplish a more comprehensive assessment. Further, training in patient advocacy and collaboration make them a natural partner in ongoing treatment. With the layers of complexity identified, effective care may begin.