Integrative Behavioral Health and the Patient Relationship: Boston Medical Center

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    • 00:00

      [MUSIC PLAYING]

    • 00:14

      KATHERINE GERGEN BARNETT: Boston Medical Center, I'mvery much in love with this institution.We're a number one trauma center.But more than that, we actually do--our sort of motto is exceptional care without exception.So we take people from all walks of lifeand provide them with the best medical care.So every single patient when they walk into our doors

    • 00:35

      KATHERINE GERGEN BARNETT [continued]: in Family Medicine, they're handed a survey.And it's called Thrive Survey.And on the survey, it really asks patients about their mood.It asks them about food insecurity.It asks them about medications.It asks them about substance use disorder.It asks them, actually, about education employmentopportunities and whether they're looking for that.

    • 00:56

      KATHERINE GERGEN BARNETT [continued]: And so our medical assistant actuallygoes through the Thrive Survey with a patientand helps them make sure that they're filling it out.Once they fill it out, the thing about the mood is called PHQ-2.So it's really just a screen for depression.There's also a screen for anxiety as well.And if that's positive, then I as a clinician

    • 01:20

      KATHERINE GERGEN BARNETT [continued]: will do a further study to do a PH2-9.So that really, then, goes into whether or notsomebody has mild, moderate, or severe depression.So it's almost like a vital sign.How are you, Tyrone?It's so good to see you.

    • 01:39

      TYRONE: I'm good.I'm actually doing really good today.

    • 01:41

      KATHERINE GERGEN BARNETT: Yeah?Tell me.

    • 01:42

      TYRONE: Today's a good day.Well, I receive all types of support.The biggest support I receive right nowis just knowing that I have a team there.But I receive support in Family Medicinefor my congestive heart failure, my pacemaker, my mental health,

    • 02:04

      TYRONE [continued]: diabetes, my epilepsy.It runs the whole gamut.So I get a lot of care and support out of the clinic.

    • 02:14

      KATHERINE GERGEN BARNETT: I have very complex patients.I have a panel that is a beautiful panel of patients.But is 175% greater than what I should have,based on how many hours I see patients.And so my patients are often double-booked or even

    • 02:34

      KATHERINE GERGEN BARNETT [continued]: triple-booked sometimes.So if I have somebody who's comingin who's having a real mental health crisis,obviously I'm going to stay there for themand really stay present for it.

    • 02:44

      TYRONE: Dr. Gergen Barnett and my relationship, as faras the care I get from her, it's a little different.It's different because we startedout not knowing each other.But I also started out not trusting doctors.So we worked on that.But a lot of that had to do with staff there, too,

    • 03:06

      TYRONE [continued]: that she works with that knew her, of her.And I didn't know of her.But they thought it would be a good fit as far ashealth-wise, trying to get my health in order.So we do all right, right now.

    • 03:21

      KATHERINE GERGEN BARNETT: What's going on?

    • 03:23

      TYRONE: Well, I spent some time with my brotherthe last couple days.I was kind of going through some issues, you know.My discomfort with going to sleep the last couple of nightshas really been tough for me.

    • 03:44

      KATHERINE GERGEN BARNETT: So you'rehaving a hard time going to sleep because you'reworried about the machine not working while you're asleep?

    • 03:50

      TYRONE: Well, yeah.I had a incident where I guess we lost power.And was I was on my CPAP.And I was just like, whoa.I woke up not right.And it really scared me.So I've been kind of worrying.

    • 04:15

      TYRONE [continued]: When I start to feel tired, I'm like, well, wait a minute.I can't go to sleep right now because what if this machineain't going to work?If I feel a palpitation or whatever, I feel just off.I'm like, wait a minute.Should I be calling right now?Should I let Doc know what's going on?I'm looking at the machine like how can I

    • 04:35

      TYRONE [continued]: keep this thing running if we lose power and stuff?So that's a little off.But I've been talking to my brother,and I've been doing what I have to do to try to Iget things right.But it's going to take some time.

    • 04:49

      CARA FUCHS: I think one of the biggest barriers to addressingbehavioral health in primary careis that, for the most part, patientsare not expecting to come in and talk about behavioral healthissues.They're coming to a primary care appointmentand expecting to talk about medical issues.So patients have varying degrees of motivation and readiness

    • 05:10

      CARA FUCHS [continued]: for mental health treatment.They have a variety of experienceswith the mental health system, some of whichhave been very stigmatizing and oppressive.And so there may be understandable reluctanceto engage in mental health treatment.So I think as opposed to patientswho are being seen in a mental health clinic where they've

    • 05:32

      CARA FUCHS [continued]: already identified that they are ready and interestedin treatment, patients that we'reintervening with in primary care may not be quite ready.And so that can be a big barrier to engagementin behavioral health services.And that's why a lot of our social work cliniciansare often really meeting patients where they are,using skills like motivational interviewing

    • 05:52

      CARA FUCHS [continued]: to really be able to acknowledge the ambivalence that a patientmight be having in engaging in behavioral health servicesand work with them at whatever stage they're at.

    • 06:05

      TYRONE: The majority of the time when you go to doctor's, Iknow when I used to go to the doctor's, the doctorwould ask me something.And You would get 10% of maybe what is true.You wouldn't get it all.

    • 06:18

      KATHERINE GERGEN BARNETT: Tell memore of what you mean by that.

    • 06:20

      TYRONE: Huh?

    • 06:20

      KATHERINE GERGEN BARNETT: What do you mean by that?

    • 06:22

      TYRONE: Because you don't go to the doctor say,listen, I'm really here for this.But I'm going to come in and say that.I want you to treat what's going to make me feel right, now.

    • 06:46

      TYRONE [continued]: And the thing about that is where we're from,you're just kind of taught at an early age,you know, I'll tell you what's wrong with you.You tell the doctor what's wrong with you.But you don't go in there and tell the doctor exactly what'swrong with you because the doctor don't need to know that.I'm telling you what's wrong with you.

    • 07:07

      TYRONE [continued]: I don't know if that makes sense.So you go in there and you alwayswould go in and give like 10%.You wouldn't tell a doctor everything.You would hope that the doctor would figure it out.And I know it is unfair because when the doctor reallydoesn't catch it, then we want to blame the doctor.The doctor's not listening to me.I want a different doctor.

    • 07:29

      TYRONE [continued]: See, it's not fair.But at the same time, it's like a cry for help.She supported a lot of the things that were differentwhen it came to my health.She's seen in between the gaps.

    • 07:50

      TYRONE [continued]: She helped me get my breathing CPAP under control.She helped me with the situation when it came to my house.And she helped me in my situationof dealing with my stress and my anxietyas well as taking the time to just doher other duties that she had to do with me because there's

    • 08:11

      TYRONE [continued]: a lot more that she has to handle with me.I was going to the diabetes clinic forever.And I could never get my count down.It was into she and I sat down and put our heads togetherand brought it from 11 down to under five.So there's a lot that we work on.

    • 08:37

      TYRONE [continued]: And I just trust her now to the pointwhere I hope that she trusts me the same way I trust her.Because there's times I come to her and say to her,I don't feel like this is working for us.And we'll take another look at it.When you're frustrated and angry the way I was at all times,

    • 08:58

      TYRONE [continued]: I couldn't even imagine what it waslike before I even met you because you saw when I met you,I was dark.But I was meeting with them before that.And it took time to get out of that and work on myselfand learn to trust and see people for who they are and notexpect people to be who I want them to be.

    • 09:19

      TYRONE [continued]: I don't know if that makes any sense.You can really see where you need to be atand where you're honestly at.When I first met you I was a little hesitant.But then it worked out.And that's how I started to learn to trust the system.I was able to let in the other psychologists.

    • 09:40

      TYRONE [continued]: I was able to let in the pharmacists.I was able to let in these other doctors.I was able to embrace them because Iknew how to navigate and advocate for myselfbecause it wasn't like you were just like,oh, this is what's wrong with you.You gave me the tools, and said I

    • 10:01

      TYRONE [continued]: think you need to check into this or try this.I would say, I tried that.And I will tell you, there were some thingsI did that set us back.And there was some things that I did that helped us.I mean, to go from having to stick myselfwith needles every day, several times a day,to being able now to have it controlled

    • 10:24

      TYRONE [continued]: and not have to worry about.It's something that I didn't think that--

    • 10:27

      KATHERINE GERGEN BARNETT: Your sugar's controlled.

    • 10:28

      TYRONE: I didn't think that I would ever get there.It shocked me when you said that.I lost it.

    • 10:33

      KATHERINE GERGEN BARNETT: Well, you cried, and then I cried.And then I think the medical assistant cried too.

    • 10:38

      TYRONE: I couldn't believe it.

    • 10:39

      KATHERINE GERGEN BARNETT: And we just freaked out.

    • 10:40

      TYRONE: I actually cried that day.

    • 10:41

      KATHERINE GERGEN BARNETT: We both cried.

    • 10:43

      TYRONE: Yeah, we did.

    • 10:45

      KATHERINE GERGEN BARNETT: That was amazing.

    • 10:47

      TYRONE: When you're going through itlike that, and the fact that we've been seizure-freenow for almost a year.I think it's tremendous when I washaving seizures like two or three times a month.I think the whole team works well.

    • 11:07

      TYRONE [continued]: And it's a funny thing because I cango in and see anybody, any part of the team,and I don't have a problem with it.I don't have a problem.Everybody pretty much knows I come to ask for this doctor.I want to see this person, see that person.And it works out really well.Dr. Gergen is definitely at the headof the team no matter what.

    • 11:28

      TYRONE [continued]: Nothing changes without her OK or her being notifiedor her being consulted on it.It doesn't happen.Dr. Klein, my cardiologist, he plays a big, big role.Diane, she plays a big role.

    • 11:48

      TYRONE [continued]: She's part of the cardiologist's team too.I have a nutritionist.I have my neuro doctor because I have really bad epilepsy,which we've been able to control.But I take a copy and everything.And I bring it to Dr. Gergen. And I present it to her

    • 12:11

      TYRONE [continued]: and say, this is it.So nobody knows if something gets lost in translation,we ain't got to worry about it.She already knows.She reviews it.She says what she thinks.And she asks me what I think because I learned that you haveto advocate for yourself now.If you don't advocate for yourself,it's not going to work.And she's actually taught me that.

    • 12:33

      TYRONE [continued]: And I think that's why my health is definitely getting better.

    • 12:38

      KATHERINE GERGEN BARNETT: I know that youhave a lot of steps, a lot of tools,that we've talked about in terms of dealing with your anxiety.Do you have particular things that you'reworking on right now to help you whenyou worry about your machine in order to get you to sleep?

    • 12:55

      TYRONE: I've been using my color steps.I've been using my mindfulness steps.I've been meditating a lot.I think that's where it's at.

    • 13:06

      KATHERINE GERGEN BARNETT: That's awesome.

    • 13:07

      TYRONE: I love the meditation.That's where it's at.

    • 13:10

      KATHERINE GERGEN BARNETT: I'm so glad.I know you and I talked about seeing Beth.Have you been able to contact her or work with her yet?

    • 13:19

      TYRONE: No.I haven't been able to work with her.I did reach out to her, and she reached back.And she was like, great, because Ithink that we can do some great work together.When you're going into, I call it a relationship,

    • 13:39

      TYRONE [continued]: with your doctors and the team, Ibelieve you have to go in there not expecting anythingbut just to see how you both can form a bondor get to know each other.It's a trust that's got to be earned.

    • 13:60

      TYRONE [continued]: Most people are kind of scared of it.They kind of don't want to go into it because, for instance,in the black community where I'm from,a mental issue is not something that you really talk about.It's like one of those, listen--

    • 14:16

      KATHERINE GERGEN BARNETT: Forbidden.

    • 14:18

      TYRONE: We're not to talk about this.What goes on in this house stays in this house.But I'm stepping outside of that.I'm going to see what's going to work for me,how can I help myself, and how can I help others.And that's the plan for that.When you start learning to advocate for yourself

    • 14:41

      TYRONE [continued]: and speak up and not be embarrassed or ashamedabout what you're going through or how you're feeling,it makes a world of difference.

    • 14:49

      BETH MARX: Very often, I'll meet someonein a warm handoff setting where a primary care doctor willcome and get me and say, hey, could youmeet with this person?And then the primary care doctor will introduce meto the patient, and say, this is Beth.I just told you about her.She'll be able to meet with you a little bitand find out what's happening in your life.I'll sit down, and then we have a little form

    • 15:10

      BETH MARX [continued]: that I fill out with the patient just tryingto find out what's happening.And then I will set the patient up for an intake.I always describe it almost like an interview,getting a sense of their mental health background,who they are, what's happening, and then either with meor another social worker on our team.

    • 15:32

      TYRONE: Beth is new to me.But I've worked with several social workersout of Family Medicine.It's sort of a funny relationship.She introduced me to the social workers.And the social workers and I would then all sit down.

    • 15:52

      TYRONE [continued]: But we have to build up our relationship now.The one issue I always felt that I hadwas that when I spoke to doctors,I felt like a lot of doctors spoke to me in terms that theyknew I would never understand.

    • 16:08

      KATHERINE GERGEN BARNETT: Using big words and stuff or what?

    • 16:11

      TYRONE: Yeah.You can't entrust yourself in a situationwhere you clearly don't understand the situation.Whether it is because of your social background or whatever,it doesn't matter.If you're talking to somebody and it's

    • 16:32

      TYRONE [continued]: supposed to be something about your lifethat you really are trying to figure out,and they're telling you in terms that you don't understand,it doesn't make sense.It's a fear.Your life is shut down.

    • 16:44

      KATHERINE GERGEN BARNETT: Fear, right.

    • 16:45

      TYRONE: But you know, you have to dothese appointments because you're not feeling well.But you don't know why.I believe that if you're working on it with a team atmosphere,you can't have any secrets.So I give my social worker 100%.If you feel something's off or you don't see something's right

    • 17:07

      TYRONE [continued]: or if you want to have a conversation about our sessionwith Dr. G, by all means, go ahead.I think that's the only way that youcan have social workers that kind of work with your doctor.And you at the same time being like,I have to be on the same page.Everyone has to know exactly what every moment is.

    • 17:29

      TYRONE [continued]: And then my social workers also will work with meand help me get my medication from the pharmacistbecause at a lot of the pharmacies,I was having problems getting my medication.So they were helpful there.It is really about just going in, just being 100%,

    • 17:51

      TYRONE [continued]: just laying it on the truth.

    • 17:52

      KATHERINE GERGEN BARNETT: Watchingyou go from being in the passengerseat of your life to being in the driver's seat of your life,that's been incredibly powerful.And then also all the other peopleyou've let into the car with me, right?So now I get to be in the passenger seat.And you're in the driver's seat.And now we're letting in the pharmacist.And he's helping with the medication.

    • 18:14

      KATHERINE GERGEN BARNETT [continued]: And we've got patient navigator to talk about your housingstuff.And you're allowing me to reintroduce youto behavioral health.And all of the people who are reallyplaying a role in your health, whichI feel really grateful for.

    • 18:31

      TYRONE: Being grateful, that's the--I say this all the time.I am grateful for the staff that came to meand were like, don't make this move.Don't leave.Trust in the system.We got you.

    • 18:48

      KATHERINE GERGEN BARNETT: I thinkit can feel really overwhelming to unearth a kind of magnitudeof grief and suffering that we encounter in patientsall the time.So just how do we as clinicians stay grounded and stay presentand stay joyful in the work?

    • 19:11

      KATHERINE GERGEN BARNETT [continued]: I think that all of primary care is really facing that challengeright now.I think the piece about really making surethat one is connecting to the behavioral health teamis inherently a challenge.And I just feel really blessed with the team that we have.And the way that I'm able to connect to them and othersare as well.

    • 19:31

      TYRONE: Patients like myself don't know whatto ask from a social worker.If you've never dealt with a social workerand have been in that environment,and you hear all this stuff about why you shouldn'tgo there or be there, you've alreadygot four strikes against you.People don't understand how all of it needs to work together.

    • 19:54

      KATHERINE GERGEN BARNETT: For me,one of the most heartening thingsabout being in medicine right now, even though there's somany complicated things about being in medicine,is the fact that we're recognizingthat this whole person care means that we'retaking care of all these other determinants of a person'shealth.And obviously, mental health is a huge part of that.But if we're not taking care of somebody's housing,

    • 20:16

      KATHERINE GERGEN BARNETT [continued]: it's really hard to take care of their mental health.And if you're not taking care of their mental health,it sure is hard to take care of their diabetes.

    • 20:23

      TYRONE: You know, you've got to beable to trust the situations and the peoplethat you're dealing with.That's why your team is critical.And I tell everybody this.If you don't have a team, you needto learn how to build a team.You need to put one together.You need to know how to advocate for yourself.A lot of people want everybody to do it for them because they

    • 20:46

      TYRONE [continued]: don't understand the system.Or they're scared to get out there.Or they're scared to ask questionsbecause they feel like people will look at them like, youshould know this.No.We have to learn this.I learned it.[MUSIC PLAYING]

Integrative Behavioral Health and the Patient Relationship: Boston Medical Center

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Abstract

Practitioners at Boston Medical Center discuss how they integrate behavioral health with primary care and how a multidisciplinary team can support patients in their holistic wellbeing.

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Integrative Behavioral Health and the Patient Relationship: Boston Medical Center

Practitioners at Boston Medical Center discuss how they integrate behavioral health with primary care and how a multidisciplinary team can support patients in their holistic wellbeing.

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