Dr. Kevin Walsh is the Medical Director for the Behavioral Medicine Service for Kaiser Permanente in Sacramento California, and he was interviewed in October of 1998 for this article. One of Dr. Walsh's duties is the oversee the work of the Behavioral Medicine Specialists (BMS) in integrated primary care (IPC). At the present time, plans call for 15 BMSs in the region. It is anticipated that there should be one BMS for each primary care unit (comprised of six physicians and a number of other professionals). At the present time, of the 15 BMS positions available, seven have been filled. Six of these positions have been filled by Ph.D. Psychologists, with one Social Worker also serving in this capacity.

Dr. Walsh has been an Internist in Primary Care for eight years with Kaiser. He stated that he was always interested in the psychological aspect of care, and as time went on, he became more and more interested in Behavioral Medicine. He reported being very intrigued by the work of such persons as Herbert Benson and David Sobel. Dr. Walsh reported he came to believe that people were coming in to see him in Primary Care because they were distressed as much as they were driven there by the presence of physical symptoms.

In his capacity at Kaiser, Dr. Walsh oversees the BMSs, as well as a variety of Behavioral Medicine classes. They have classes in coping skills, panic disorders, fibromyalgia, chronic pain, relaxation training, and so on. He reported that Kaiser is attempting to develop a specific treatment pathway for common disorders.

According to Dr. Walsh, the new integrated primary care paradigm is a very cost-effective one. He stated, "It is exciting. It is really a win-win situation. It is what the patients have needed all along - which is care for their distress - and it saves money too." Dr. Walsh reported that the Kaiser plan calls for one BMS for each 20,000 persons in the population. This equals one BMS for each six Primary Care physicians. He reported that at the present time, there are different ways that this has been implemented. He reported that some teams are rotating BMSs, with psychologists working as a BMS for a period of time, and then serving in some more specific capacity, such as the treatment of chronic pain or substance abuse.

Dr. Walsh noted that one of the primary roles of the BMS was to be a diagnostician. He went on to say that at the present time, the assessment of patients in the new Kaiser system involved primarily medical tests. At the present time, psychological tests have not been used heavily. He stated, "Psychological tests have not been a big part of our system, we rely more on clinical testing and exams. I think there is tremendous room for utilizing psychological tests though."

Physicians have reacted in different ways to the new system. Dr. Walsh noted that the younger, more progressive physicians have adjusted to this easily. However, he stated that some of the older more conservatively trained physicians were initially skeptical of the inclusion of BMS in primary care. Dr. Walsh recalled that in 1995 when this system was first piloted, there were a small number of physician skeptics. He stated though that after four to six months, everybody became a big proponent of the new system. Dr. Walsh stated, "The system was very convincing. Even for the skeptical physicians. As soon as they experienced one situation where a BMS would step in and handle a panicked or suicidal patient, and resolve the problem, they were sold."

Dr. Walsh also noted that initially some of the Psychiatrists on staff at Kaiser had some reservations the BMSs giving advice to primary doctors, especially when medication was being considered. However as roles and expectations are being clarified, they are becoming more supportive of the system. In an effort to improve quality around issues of medication, the psychiatrists have established a "Mind-Phone" staffed by psychiatrists who can provide immediate consultation to either the PCP or BMS when needed.

In the Kaiser system, psychiatrists are specialists. Persons with more serious psychiatric disorders are referred to Kaiser psychiatrists, and treated by them. In this scenario, psychiatrists become the specialists to which a BMS can refer. Again, however, Dr. Walsh noted that psychiatry is reserved for dealing with more severe disorders, whereas more run-of-the-mill depression or anxiety is treated by the primary care provider in conjunction with the BMS.

Dr. Walsh noted that the advantage of this system is that it saves the intensive psychiatric resources for the people who have greater needs. Dr. Walsh said, "To me, that seems like a better idea, to have those services more available for the people who need it the most."

Dr. Walsh stated that he had become an ardent supporter of the new integrated primary care system. He stated, "Speaking as a PCP, I cannot imagine going back. It would be unfathomable to go back without my psychologist buddy. When you have 15 minutes with the patient, you just can't get the job done. To be effective, it is such an incredible help to just to walk down the hall and introduce the patient to your psychologist colleague. It is awesome. It has made my life so much easier."  

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