Behavioral Science and Family Medicine
Collaboration: A Developmental Paradigm
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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In reacting to the series of articles
(Tamily Systems Medicine 10, 1992) on
whether "there is a future for behavioral
scientists in academic family medicine,"
the authors address the problem in a
systemic manner. Despite the incredible
advances in biomedicine, the need for
extended models that include a biopsycho-
social and family orientation is essential
for maintaining family medicine as an
academic discipline. To do this demands
the collaboration and integration of the
behavioral sciences that are basic to these
extended models. This collaboration is
dependent on a number of changing devel-
opmental phases of each of the major
factors related to behavioral science, family
medicine departments, and patient popula-
tion within the context of the medical care
and political-societal systems. The major
elements of this paradigm are incorpo-
rated into guidelines for collaboration. The
high quality, diversity, and flexibility of
this dynamic collaboration makes for an
optimistic outlook that this relationship
will successfully adapt to future medical
care and societal changes.
Fam SystMed 11:15-23, 1993
t Dorothy Jones Weatherhead Professor Emeritus,
Department of Family Medicine, Case Western
Reserve University, 10900 Euclid Avenue, Cleveland
OH 44106-7136.
$ Assistant Professor, Department of Family Medi-
cine, Case Western Reserve University; MetroHealth
Medical Center, Cleveland OH.
15
Family Systems Medicine, Vol. 11, No. 1, 1993 © FP, Inc.
JACK H. MEDALIE, M.D., M.P.H.f
KATHY COLE-KELLY, M.S., M.S.W.t
T HE fall 1992 issue of Family Systems
Medicine contained a fascinating and
stimulating series of articles about the
future of behavioral scientists in academic
family medicine (see Shapiro & Talbot, 10)
or in primary care medicine (see Bloch, 4).
Shapiro and Talbot have raised some
important, general themes. They conclude
that collaboration should center on multi-
problem patients, research, and consult-
ants to the system. The Michigan group of
authors (2,3) detail their roles in specific
situations, highlighting the diversity of
roles and ideas that exist and the many
ways in which this has made collaboration
flexible enough to meet local needs and
interests. This is followed by stimulating
articles by McDaniel (7), Ransom (9), Stein
(11), and Antonovsky (1) about their views
of the general situation. As can be ex-
pected, their views have been greatly
influenced by their personal experiences.
These experiences have been very positive
for the first three authors; therefore, they
are upbeat and optimistic. Antonovsky's
experiences are somewhat mixed, so he is
skeptical about the future. He also hap-
pens to be the only nonclinician in the
symposium, and this might be an impor-
tant factor related to the collaborative
process.
In our response, we will react to some
specific points, but mainly we will try to
look at the question in a wholistic, or
should we say, more systemic way. The
 16 /
future of behavioral scientists in family as part of the health service, they become
medicine is an important topic with many salaried like any other integrated partici-
ramifications. To do justice to the theme pant. Theoretically, this should make a
demands that we first look at some of the great difference to the role of the behav-
wider societal and medical issues that ioral scientist in the two countries because
influence our medical system, before look- one is, and will be, accepted primarily on
ing at the relationships within one of the the basis of economics, and the other,
disciplines—family medicine. primarily on the basis of professional
The political system of government is an status. This obviously influences their
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important factor influencing the medical respective roles in departments.

system. It is interesting that the authors of Further general points are worthy of
the lead article, Shapiro and Talbot (10), mention. Despite amazing results and
are from the United States and Canada, discoveries arising from the biomedical
respectively. The U.S. system is a private, model and its continued dominance in
insurance-driven system (about 1,500 in- family medicine and medicine as a whole, it
surance agencies are involved) with some seems that many commissions, confer-
federal and state controls relating to ences, committees, and individuals (see
quality and costs. This semi-private, hap- 5,8,12) have concluded that the biomedical
hazard system has led to a number of model does not and cannot meet all the
anomalies, such as a high percentage of the needs of modern medicine. Thus, both the
gross national product (GNP) being spent G.P.E.P. Report (8) and the Wickenburg
on medical care, a high-quality, technologi- Conference (6,12), among others, have
cally driven system with nearly 40 million strongly reaffirmed the need for behavioral
uninsured and at least another 50 million science courses and contacts in undergrad-
with inadequate insurance—together, ap- uate and graduate medical education, as
proximately 1/3 of the population. Pri- well as in clinical practice. The majority of
mary care, although important, takes a the medical establishment still believes
secondary position in respect to specialist that the ideal physician is a "humane
and subspecialist care. In Canada, the person practicing the biomedical model."
national health insurance scheme is con- One must ask if a physician can be humane
trolled by the national and provincial without understanding the psycho-social-
governments, with the primary care practi- cultural-historical aspects of the patient,
tioner as the backbone of community of himself or herself, and of the wider
services. In essence, this difference means, society? We believe that with very rare
we believe, that the dominant factor in the exceptions, the answer is no!
U.S. system is profit-making for the pri- In a sense, family medicine as a disci-
vate insurance companies and the clinical pline believes that the biomedical model
practitioners, whereas the Canadian sys- needs expansion, so family doctors use
tem appears to be driven by a need to other models when the situation demands
provide a health service to the whole it, and behavioral science exposure is an
population in the least expensive way. This official requirement of residency training
means that the majority of behavioral accreditation. The models used in family
scientists in the U.S. have to "pay their medicine include: the biomedical, the bio-
own way" by clinical fees or grants, psychosocial, the family systems, the devel-
otherwise they will be excluded from the opmental (life cycle), the relational, and
current system. In Canada, it seems that the epidemiological. By using these mod-
once behavioral scientists are "accepted" els, family medicine has made it clear that,
 MEDALIE and COLE-KELLY
in order to deal with a multicultural and
socioeconomic patient population, it needs
multiple models and professionals from
multiple disciplines.
These disciplines can be divided into
clinical and nonclinical categories and
include representatives of numerous dis-
ciplines working in family medicine de-
partments, such as psychologists, social
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workers, psychiatrists, sociologists, anthro-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
pologists, epidemiologists, family thera-
pists, ethicists, biostatisticians, and so on.
The Shapiro-Talbot article (10) and other
articles (1-3,7,11) refer mainly to the
clinicians such as psychologists, social
workers, and family therapists as the
behavioral scientists. The other disciplines
mentioned above, although not referred to
in the original article (10), have similar
problems related to their future in family
FIG. 1. Behavioral science-family medicine interaction.
Fam. Syst. Med., Vol. 11, Spring, 1993
/ 17
medicine and, for lack of a better term,
they are often included in the same
behavioral science category. For the pur-
pose of this article, we will concentrate on
the clinical behavioral scientists, but will
mention some of the others and reflect on
the position of the family physician.
Given this background, it is obvious that
we believe that behavioral scientists have
had and will continue to have an important
role in family medicine education, re-
search, clinical practice, and administra-
tion. The question is how do we see this
relationship or collaboration continuing in
the future.
To look at the relationship between
behavioral scientists and family medicine
academic departments, the overall picture
can perhaps be illustrated by a modified
Venn diagram (see Figure 1). The figure
Family
Medicine
Departments
 18 /
illustrates that the interaction and overlap
between behavioral scientists, family med-
icine departments, and patients can be
fully understood only when seen in interac-
tion with the broader context of the
medical care and the larger political-
societal system. Looking at the left inner
circle of the Figure, it would be nice to
start with the proviso that all clinical
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behavioral scientists are mature, experi-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
enced, efficient, and adaptable profession-
als. Unfortunately, like all representatives
of other disciplines, they consist of many
types in varying stages of maturity and
development. Their individual interests
range from clinical work with the individ-
ual to thinking systemically about, for
example, families and organizations.
The right inner circle of Figure 1 relates
to academic family medicine departments.
For our purposes, these departments can
be divided into various categories or stages
of development, ranging from those more
resistant to the integration of the behav-
ioral sciences to those most supportive:
1. The first category includes depart-
ments in which the chair and faculty do
not identify with or accept the biopsychoso-
cial model, or the importance of behavioral
science, but do recruit a representative of
the latter because residency accreditation
decrees it. If an individually oriented,
clinical behavioral scientist is recruited
into this situation, he or she might fit in
well as a specialist-consultant, but will
likely remain isolated and have little
influence or opportunity to become inte-
grated into the departmental system. On
the other hand, if a mature systemic-
oriented clinician is recruited, this person
might, over a number of years, influence
the faculty's teaching, organization, and
practice in a meaningful way. This evolu-
tion would take a lot of confidence, support
from other colleagues, and a dose of
eternal optimism! This determined jour-
ney might lead the behavioral scientist to
become an integral member of the depart-
ment, with academic status and responsi-
bility for certain departmental activities.
This success might even be reflected in the
integration of the biological and psychoso-
cial spheres.
2. The second category includes depart-
ments that have a chair and a limited
number of faculty with a theoretical or
intellectual commitment to behavioral sci-
ences as a core component of family
medicine, but, in actuality, there is little
application of this commitment in every-
day clinical practice. Such a situation
requires the behavioral scientist to be
ever-alert to those most sympathetic to the
psychosocial integration and to capitalize
on their inclinations. A variation of this
stage might be a department that accepts a
behavioral scientist into its research and/or
educational activities, but, like the clinical
work, this is primarily done in a separatist
rather than a collaborative mode. Again,
this situation would demand that the
behavioral scientist be continuously en-
couraging those who are theoretically
committed to work collaboratively.
3. A third stage is a variation of the
previous one. There is a critical mass of
physician faculty accepting and supporting
behavioral scientists, but the chair is not
an active promoter of them. The opportu-
nity for good collaboration and integration
is there, and the right behavioral scientist
may well be able to seize it. The one risk in
this faculty dynamic is if the chair feels
threatened by the medical and behavioral
science faculty. This insecurity could lead
to a thwarting of creative collaborative
ventures and lead to a disintegration of
enthusiasm by a significant subset of the
critical mass, thus leaving the behavioral
scientist in a less supportive environment.
The critical mass of physician faculty and
behavioral science faculty need to be
careful to include the chair in all phases of
the collaboration.
 MEDALIE and COLE-KELLY
4. The final stage is represented by the
few departments that have successfully
traversed the initial educational and devel-
opmental processes. These have reached
the stage where clinical and nonclinical
behavioral scientists have appropriate aca-
demic appointments, are fully integrated,
and play important roles in the clinical,
research, educational, administrative, and
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social activities of the department. In these
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departments, the medical as well as the
behavioral science faculty are active pro-
moters of a biopsychosocial/systems ap-
proach. It is probably in these departments
that innovative, new methods of collabora-
tion will develop to meet changing needs
and conditions.
We are implying from the above that the
process of behavioral science-family medi-
cine collaboration is a dynamic, complex
process, dependent on the interaction of a
number of developmental stages of the
major factors shown in Figure 1. Although
this interaction is molded and to some
extent controlled by the medical care and
political-societal systems, the future of
behavioral science in family medicine de-
pends primarily on a mutuality of purpose,
planning, and execution by the chair
and/or faculty, and by the behavioral
scientist. This has been occurring over the
last decade by dedicated people, but in a
haphazard and unstructured manner. For
those of us whose bowel training was not
too strict, this flexible framework had a
number of positive points, but it seems
that we have reached the stage where a
more formal structure or guidelines are
needed.
In general terms, we suggest the follow-
ing guidelines for any department or
program that is beginning or restructuring
its collaboration with behavioral science:
1. Assess the stage that the department
has reached.
2. Assess the resources and support avail-
able in the department.
Fam. Syst. Med., Vol. 11, Spring, 1993
/ 19
3. Assess the interest and motivation of
the chair and senior faculty and decide
who will provide the leadership for this
collaboration.
4. Decide on the type of behavioral scien-
tist needed: clinician or nonclinician. (If
clinician, is a generic clinician suitable
or is a specialist needed, for example,
family therapist or someone to deal
with a specific problem like substance
abuse or child abuse? If a nonclinician,
is an educationalist needed, an anthro-
pologist, a statistician, or some other
type?)
5. Recruit the individual behavioral scien-
tists).
6. The behavioral scientist, with good
representation of the faculty and the
chair (who must be involved in order to
show her or his support), must jointly
make decisions about (a) short and
long-term objectives; (b) the opera-
tional plan; and (c) an ongoing evalua-
tion process.
7. It would be appropriate to obtain consul-
tation from people who have traversed
the process.
Having discussed some general princi-
ples of the collaboration, we will now
comment on some specific points brought
up by the authors in the last issue
(1-4,7,9-11).
Connection with One's Own Profession
One point discussed was whether there
should be a full transition to or dual
identification with family medicine. Ran-
som (9) described the shifts, difficulties,
and ambivalence that occur when behav-
ioral scientists gradually become more
involved with family medicine than with
their original discipline. He seems to imply
that the end result is when behavioral
scientists come to terms with themselves
they will make the full transition to family
medicine. We feel that this full transition
is an important step in development, but,
 20 /
also, that everyone should and must
maintain contact with his or her own
discipline through the literature, meet-
ings, and so on. This dual identification
can and does lead to some ambivalence, but
it must be done so that behavioral scien-
tists can remain in contact with new
developments in their discipline while
feeling invigorated and at home in their
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new discipline—family medicine. This can
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be done by attending the Amelia Island
conference, Society of Teachers of Family
Medicine (STFM) conference, North Amer-
ica Primary Care Research Group confer-
ence, in addition to their own conferences
and meetings. This dual identification
should be dual invigoration and stimula-
tion to the benefit of both the individual
and the discipline.
Although the symposium authors talk
about this as a problem for behavioral
scientists, in many respects it affects all
disciplines in family medicine, including
nurses and family physicians. For family
physicians to keep current with clinical
developments, they must attend general
medicine or other conferences, participate
in the meetings of the American Academy
of Family Physicians, and usually read one
or more nonfamily practice medical jour-
nals. The ambivalence Ransom writes
about can also affect young family physi-
cians, and can be adjusted to only when a
certain stage of maturity, experience, and
self-confidence has been reached. Uncon-
sciously, the annual STFM conference has
become an integrated affair where all the
diverse disciplines in family medicine meet
as friends and colleagues and learn to work
together without emphasizing any particu-
lar discipline. It is also a place where you
discover a national network of others
embarked on a similar adventure of discov-
ery. Dual identification is something every
professional in family medicine has to
contend with. Despite the difficulties, it
can and should be stimulating.
Role of the Behavioral Scientist
The behavioral scientist serves as con-
sultant to the system, not as therapist for
the personnel. Like other aspects of the
relationship, the consultation process has
a life cycle of its own. The first stage occurs
when the family medicine chair realizes
the value of the behavioral scientist in
recruitment and evaluation of potential
faculty, staff, or residents. Sometimes the
relationship gets stuck at this stage, with
the behavioral scientist doing more and
more evaluations and even counseling or
therapy of other departmental members.
Behavioral scientists who do not feel
valued for other contributions might be
susceptible to providing this role in hopes
of establishing themselves. If this happens,
it leaves them vulnerable to a number of
triangulation situations within the depart-
ment, which will often negate their poten-
tial as behavioral scientists and should be
carefully guarded against. Counseling and
therapy for personnel should be referred
out of the department. Once the therapy
role is eliminated, the consultation process
can more properly focus on help with
interpersonal and organizational prob-
lems. The next step is incorporation of
behavioral scientists into departmental
committees, their taking responsibility for
certain activities, and finally serving on the
departmental executive committee. The
consultation process is an important contri-
bution of the behavioral scientist, but it
should not and must not become confused
with being a therapist for other personnel.
The Chair's Role
Most contributors to the symposium
emphasized the important role of the
behavioral scientist in the collaboration
with family medicine. We agree that this
role is vital, but, like all relationships,
many other factors are involved (see
Figure 1). One of these factors, which we
believe is understated and underesti-
 MEDALIE and COLE-KELLY
mated, is the attitude and behavior of the
chair. Like any family group, the family
medicine department is greatly influenced
by the leadership and role modeling of its
parent(s). This leadership and parenting of
the chair is vital, whether done by the
chair or delegated to another faculty
member. In the latter instance, the collab-
oration will succeed only if the chair
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actively supports and fosters the relation-
ship.
In general, we have long felt that our
discipline/specialty should have a struc-
tured training program for chairs. This
program would or should extend the
training beyond organizational, financial,
and administrative aspects to include dis-
cussion of basic topics like the biopsychoso-
cial and other models, as well as practical
aspects of collaboration with all behavioral
scientists. This would allow the chairs to
define the goals and objectives of the
department more clearly, hopefully provid-
ing better-informed partners to the behav-
ioral scientist for mutual collaboration.
Will Behavioral Scientists Be Replaced?
We have often heard or read that when
family physicians are adequately trained in
the psychosocial mode there will be no
place for behavioral scientists. (This might
be called the extinction anxiety syndrome!)
This fear or anxiety is a myth and has no
basis in fact. On the contrary, it is a
common experience that the more training
physicians have in the field, the more they
appreciate its importance and the more
they will want to collaborate with behav-
ioral scientists. Looking at current depart-
ments of family medicine should convince
the most anxious skeptic that, with few
exceptions, the departments with psychoso-
cially trained family physicians have more
extensive programs and more well-trained
behavioral scientists in more developed
roles than do other departments.
Fam. Syst. Med., Vol. 11, Spring, 1993
/ 21
Nonclinician Behavioral Scientists
This group includes professionals from
many disciplines—for example, sociolo-
gists, anthropologists, statisticians, educa-
tors, and ethicists. It is in the research and
educational fields where the contributions
of these people are important. The key to
their success in family medicine depends
on factors similar to those discussed
previously with regard to clinical behav-
ioral scientists. In addition, there is one
important factor that nonclinicians face
daily: they must be able to make their
teaching and research relevant to the
clinical practice of medicine. If students,
residents, or faculty feel that it is not
relevant or applicable to their everyday
work, they will not succeed. Unless the
material can be shown to be relevant,
trainees will not be motivated to accept it.
This probably means that most teaching
should begin with common clinical exam-
ples and then have the principles and
concepts develop from these examples.
This demands from nonclinicians an ongo-
ing observance and absorption of the
family practice culture in order to inte-
grate their field into family medicine. This
is a difficult but vital task if they are to be
anything more than outside consultants.
The Family Physician
Most students who choose family prac-
tice as their career probably will have some
feeling (dormant or not, depending on
their medical school training) for the
biopsychosocial aspects of health and dis-
ease. Whether this feeling is fostered and
allowed to develop or whether it will be
rejected or denied will depend on the
atmosphere and training in their residency
program, as well as their personal experi-
ences with patients (the ah-ha! experi-
ence), a poignant life cycle, or illness-
related experience in their own lives, and
on the behavioral scientist with whom they
have to work.
 22 /
The further development of the psycho-
social side takes various forms. Some
trainees accept it quickly and become
staunch advocates and practitioners for
the rest of their careers. Some initial
enthusiasts might have a later reaction to
it and tend to downplay it until they find a
modus vivendi and adjust to the integra-
tion of the biomedical with other models.
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Some gradually become more accepting of
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the newer concepts and widen their activi-
ties when they feel it is needed. Others
reject it and stay with the traditional
biomedical model, which sometimes uncon-
sciously directs them into certain allied
fields like sports medicine or urgent care.
The adjusted, mature family physician
who understands and uses psychosocial,
developmental, and family issues in every-
day practice and, when needed, uses appro-
priate consultation or referral, should be
the objective of our family medicine train-
ing programs.
CONCLUSION
We believe that there are a number of
complementary issues around this collabo-
ration:
1. Despite the advances of molecular
biology and the dominance of the biomedi-
cal model, there is a need to extend and
supplement these by the use of the biopsy -
chosocial and other relevant models.
2. To do this, we believe that the
integration of behavioral science and fam-
ily medicine in clinical practice, research,
teaching, and administration is essential if
family medicine is to maintain its integrity
as an independent academic discipline.
3. Departments of family medicine, like
culture and families, come one at a time
(11, p.300). There are many ways of
accomplishing this collaboration, taking
into consideration the interrelated factors
of behavioral science, family medicine,
patient populations, medical care, and
political-societal systems (see Figure 1).
4. The interrelationship is a dynamic
process that depends on the stage of
development of each of the major factors
mentioned above and detailed earlier in
this article.
5. The developmental and dynamic
phases are flexible enough so that this
collaboration will succeed in adapting to
future changes in medicine and society.
6. The caliber of the people involved
makes us optimistic about the future
collaboration and integration of behavioral
science and family medicine.
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Fam. Syst. Med., Vol. 11, Spring, 1993
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