Behavioral Medicine Service

Overview

The Behavioral Medicine Service is a psychological consultation and intervention program integrated within team-based interprofessional specialty medical services of Yale-New Haven Hospital (YNHH) and Smilow Cancer Hospital. Fellows train within interprofessional teams of physicians, surgeons, nurses, social workers, and psychologists while gaining valuable experience in the provision of behavioral health consultation, psychological assessment, and evidence-based behavioral health intervention with a broad range of medically ill patients. Emphasis is placed on understanding biopsychosocial factors that influence health and illness and applying this knowledge along with behavioral interventions to prevent disease, improve disease management, increase quality of life, and facilitate end-of-life planning and care needs.

Placement Options

PRIMARY PLACEMENT - This track consists of a single, full-time, twelve-month placement within YNHH's Psychological Medicine Service. (There are no secondary placements within YNHH).

Number of Fellows

Three doctoral fellows will be selected into the Behavioral Medicine track for the 2023-2024 academic year.

The Setting

The Behavioral Medicine Service, developed in 2008, is part of the Psychiatric Services of Yale New Haven Hospital. The Service includes a large and growing community of psychologists and is a valued and integrated component of Yale-New Haven Hospital and Smilow Cancer Hospital. Clinical training for Behavioral Medicine fellows occurs within several interprofessional team-based specialty care centers within Yale New Haven Hospital and the Yale School of Medicine.

The Internship

The goal of the Behavioral Medicine Service is to provide behavioral health expertise as a co-treating discipline to patients seen by interprofessional treatment teams linked with the referring medical specialty so that the patient’s emotional and behavioral health needs can be addressed within the context of their overall medical care. The service operates under the premise that integrated behavioral medicine has the potential to benefit both patients and providers by improving access to behavioral health care for medically compromised individuals. Primary goals of this service are to: improve adherence and adjustment to medical illness and medical treatments; target psychosocial issues, lifestyle and health behaviors (e.g., physical activity, dietary practices, sleep, tobacco and other substance use) affecting health and wellness; address issues of pain management, stress tolerance, addictions, and coping; and to help prevent the development of more serious mental health disorders through early detection and intervention.

Behavioral Medicine fellows receive in-depth training within a number of team-based specialty medical services that align with their primary training goals and interests, while also receiving training in core health behavior domains (sleep, smoking and pain) that are common between clinical services and patient populations.

Within each of these medical services, Behavioral Medicine fellows consult with medical providers and their interdisciplinary teams and provide evidence-based assessment and intervention services to medically ill patients using evidence-based behavioral, cognitive-behavioral, acceptance-based, and mindfulness-based therapeutic approaches.

Fellows also attend and participate in a number of weekly multidisciplinary team meetings and case conferences. These may include Psychological Medicine case conferences and service rounds, Tobacco Treatment Service team meetings, inpatient Palliative Care Rounds, Palliative Care Interdisciplinary Team Meetings, Liver Transplant Recipient Review Committee, Liver Donor Advocacy Meeting, Sleep Medicine conferences, the Peripheral Vascular Interventions (PVI) conference, and a host of other interdisciplinary seminars and workshops with advanced fellows in psychiatry, pulmonary care, sleep medicine and internal medicine, (cardio)vascular medicine, depending on their current rotation.

Primary and Secondary Clinical Placements:

Fellows receive training within several Interprofessional Team-Based Specialty Care Centers of YNHH and the Yale School of Medicine.

Fellows have the ability to choose two 6-month Primary Rotations based on their training goals and primary areas of interest. Primary rotations may occur within any of the following programs: cardiovascular medicine, digestive health, organ transplant, or psychosocial-oncology/palliative care. Primary rotations typically involve three days a week of onsite training.

Interprofessional Team-Based Specialty Care

Primary Rotations (Fellow chooses two (2) Primary Placements and receives all three Secondary placements)	Cardiovascular Medicine (6 mo)	Digestive Health (6 mo)	Transplant (6 mo)	Psychosocial-oncology (6 mo)

Core Health Behavioral Domains

Secondary Rotations	Tobacco (4 mo)	Sleep (4 mo)	Pain (4 mo)

Example:

Fellow A

• July-December: Psychosocial-oncology/Palliative Care
• January-June: Transplant

Fellow B

• July-December: Cardiovascular Medicine
• January-June: Digestive Health

Fellow C

• July-December: Digestive Health
• January-June: Psychosocial-oncology/Palliative Care

Primary Rotations in Interprofessional Team-Based Specialty Care

(Choose two)

1. Cardiovascular Medicine (6 months)

The Vascular Medicine clinical program at Yale has grown exponentially over the past decade and has profiled itself as a destination center nationwide for complex vascular disease pathology. It is one of the largest academic vascular medicine programs in the nation, and includes the ground breaking Vascular Medicine Outcomes (VAMOS) program, one of the nation’s few outcomes research programs dedicated to vascular populations, led by Drs. Smolderen (psychologist) and Mena-Hurtado (interventional cardiologist). The combined peripheral vascular disease population served system-wide by YNHH in the past decade is more than 117,000 patients, with over 2000 patients receiving lower-extremity peripheral vascular interventions annually as well as carotid artery stenting interventions for complex vascular disease.

The new pioneering integrated behavioral medicine program overlayed onto the interdisciplinary setting of vascular medicine is the next phase of growth. Fellows rotating in the cardiovascular behavioral medicine program will be exposed to an interdisciplinary setting, training alongside with interventional peripheral and cardiology fellows, vascular medicine outcomes research fellows, and trainees with a background in biomedical and health informatics. This signature program will train the next generation of leaders that design and test models of care targeting psychosocial factors as ways to improve cardiovascular care and outcomes, and specifically models of care that include scientist-practitioners that are experts in the study of human behavior and health as part of a co-treating specialty of the larger multidisciplinary care team.

Lower-extremity peripheral artery disease (PAD) is one of the most prevalent and burdensome vascular chronic diseases globally, with over 8.5 million individuals affected in the U.S. alone. Patients with PAD present with unique multimorbidity risk (atherosclerotic) profiles, health behaviors (high smoking rates, ambulatory problems that prevent exercise), and mental health profiles, such that tailored applications of integrated care models need to be applied for the PAD population, a role that clinical psychologists are equipped to fulfill. This program targets behavioral risk factors, psychological diagnostic evaluation and treatment for common co-occurring mental (depression, anxiety, and post-traumatic stress disorder), address adherence concerns, and adaptation and support programs for patients undergoing major amputation (self-image, coping, role of social support, self-management, etc).

This rotation will heavily focus on the scientist-practitioner model and you will interact with the interdisciplinary vascular medicine team as well as with the VAMOS research program supporting the clinical program. A big focus of our program and a test to all of the work VAMOS does, is whether it meets the standards of patient-centered care as seen from the patients’ and their families’ perspective. In addition, it aims to test and implement through clinical trial programs integrated care pathways that are patient-centered, and address behavioral aspects. As an example, support programs, stress reduction programs, psychosocial assessment, and collaborative and patient-preference sensitive depression treatment pathways are part of ongoing research programs that will blend in the clinical services that the fellow will help support. In addition, it has developed the framework for a shared decision making tool https://showme-pad.org/ for patients with lower-extremity peripheral artery disease, which will serve as a foundation for a variety of patient populations going forward. Key to our work are partnerships with patient experts and their families, as they have guided our insights and work throughout the past decade. Lastly, we have in-house expertise on leading and overseeing complex analytic frameworks for understanding critical quality of care and outcomes questions in large databases. It has also formed a close relationship with the Center for Computational Health to develop our own internal vascular research data warehouse at Yale New Haven Health Hospital. These investments would allow us to create datamarts to answer various clinical outcomes questions as they pertain to patients’ behavioral health and subsequent health outcomes.

Our program has two clinical health psychologists on staff that will provide mentorship throughout the rotation. You will participate in weekly peripheral vascular service sign out meetings and monthly interdisciplinary patient conferences. Outpatient clinics are located throughout the greater New Haven area and provide a wide variety in case mix and opportunities for in-person consultation services as well as telehealth services delivered to vascular patients in the wider Connecticut area.

2. Digestive Health (6 months)

Yale New Haven Health’s comprehensive Digestive Health Service offers patients the most advanced and effective medical, surgical and psychological treatments for gastrointestinal issues. The service’s experienced team of providers work together to coordinate the best care for each individual through consultations, screenings, diagnosis and treatment.

Within the Digestive Health placement, fellows learn about the field of psychogastroenterology and train within a vibrant and growing interprofessional program of gastroenterologists, surgeons, nurses, social workers, nutritionists and physical therapists to learn about the biopsychosocial aspects of treating patients with gastrointestinal conditions such as inflammatory bowel disease (Crohn’s, ulcerative colitis) gastroparesis, celiac disease, and other functional disorders of gut-brain interaction.

Within this placement, fellows work closely with a licensed faculty psychologist to provide evidence-based assessment and intervention to a diverse range of patients presenting with chronic and functional gastrointestinal conditions. Psychological interventions for functional disorders such as IBS directly target the gut-brain interaction believed to be perpetuating symptoms. Within this placement, fellows are exposed to and develop competencies in the use and implementation of evidence-based psychotherapies including cognitive behavior therapy, acceptance and commitment therapy and gut-directed hypnosis in the context of Digestive Health. Fellows also assist patients with an array of co-occurring challenges namely, adjusting to chronic illness, attaining disease self-management skills, addressing medication adherence, behavioral weight loss, and treating co-morbid depression and anxiety.

3. Psychosocial-Oncology/Palliative Care Rotation (6 months)

The Yale Cancer Center and Smilow Cancer Hospital combine a tradition of innovative cancer treatment and quality care for patients. Yale Cancer Center is Connecticut's only cancer center designated as a Comprehensive Cancer Center by the National Cancer Institute—and one of only 49 in the nation. National Cancer Institute centers are national leaders in cancer research, prevention, detection, and treatment. Smilow Cancer Hospital provides patients with novel, state-of-the art cancer detection and treatment options within the context of patient-centered expert care.

Within Smilow Cancer Hospital, Behavioral Medicine fellows train within several overlapping clinical services: (1) Outpatient Psycho-Oncology Clinics (2) Inpatient Palliative Care Service, and (3) Outpatient Sexuality, Intimacy and Menopause Clinic.

Within Smilow Cancer Hospital’s outpatient oncology clinics, fellows provide co-located evidence-based individual psychotherapy to referred patients. Patients may be referred from any cancer-specific disease team and may be at any stage of illness. Patients are referred for a variety of reasons (e.g., emotional distress, pain, sexuality, body image, managing addictions, end of life concerns, etc.) and may be seen individually or with a partner or other family member. Fellows work closely with the patient’s oncology team (oncologists, advance practice nurses, social workers, and nurses) to provide coordinated oncology clinic-based care. Fellows also have the opportunity to attend Palliative Care Interdisciplinary Team Meetings, disease specific tumor board meetings, Yale Cancer Center’s Grand Rounds, and Schwartz Rounds.

During inpatient Palliative Care rotations, fellows function as a member of the multidisciplinary palliative care consult team, attend daily rounds, and work closely with palliative care physicians, advanced practice nurses, social workers and chaplains. Fellows provide bedside consultation and brief evidence-based interventions to address issues related to pain, emotional distress and end-of-life. Training goals on this rotation include exposure to inpatient multidisciplinary team care, increased understanding of issues faced by individuals with advanced cancer approaching end of life, assessing goals of care, and the utilization of brief bedside therapies to address physical/emotional distress, mortality and existential issues.

Behavioral Medicine fellows also participate in the Cancer Center’s Menopause, Intimacy and Sexuality (SIMS) Clinic—a unique twice a month interprofessional clinic within the Department of Gynecology-Oncology. Here, fellows train closely with a faculty gynecologist and gynecology-oncology fellow and perform brief behavioral health consultations with women who have a history of cancer and whose primary concerns relate to sexuality, sexual functioning, body image, or menopause.

4. Transplant Rotation (6 months)

The Yale-New Haven Transplantation Center (YNHTC) provides expert, comprehensive and compassionate care for adult and pediatric patients throughout the world who are candidates for organ transplantation. The YNHTC specializes in liver, kidney, pancreas, and heart transplantation; and is the region's leader in the evaluation and treatment of advanced liver disease.

Within the Yale New Haven Transplantation Center, fellows gain valuable experience with issues related to organ allocation, patient selection, transplant ethics, and the psychological and neurocognitive functioning of patients with acute organ failure and end stage liver and kidney disease. Fellows play a number of important roles in the evaluation and on-going support of liver and kidney transplant candidates. Specifically, fellows provide co-located individual behavioral weight loss, drug and alcohol relapse prevention counseling, smoking cessation, and stress management and relaxation training to adult pre- and post-transplant patients.

Fellows also spend one-half day per week within a multidisciplinary Pediatric Hepatology Clinic and provide consultation along with physicians and nutritionists to patients and families coping with fatty liver disease. Finally, fellows also receive specialized training in the evaluation of live liver donors and participate in the program's Donor Advocacy Team. Within the transplant program, fellows attend and participate in weekly multidisciplinary meetings and case conferences such as the Liver Transplant Recipient Review Committee and the Donor Advocacy Meeting.

Secondary Rotations in Clinical Health Behavior Domains (Required)

Pain Medicine (4 months)

The Yale New Haven Hospital Spine Center, part of the Center for Musculoskeletal Care at Yale School of Medicine and Yale New Haven Health, provides multidisciplinary outpatient services for acute and/or complex spinal conditions. Back ailments and pain are very common, and the Spine Center focuses on a personalized approach that includes surgical and non-surgical options with a goal of improving a patient’s condition and quality of life. The pain medicine program is one option that is usually offered to all patients who are interested, with referrals being made from the Spine team’s physiatrists, anesthesiologists, physical therapists, and surgeons. Pain medicine utilizes empirically supported behavioral interventions and offers a comprehensive approach to the management of persistent pain and related conditions.

Within the Pain Medicine Program, fellows work closely with a licensed clinical psychologist to receive specialized training in motivational interviewing and cognitive-behavioral therapy to promote behavior change and treat persistent pain. Fellows also receive some training in the evaluation of other comorbid disorders, such as addiction, anxiety, and depression, as well as psychological evaluations specific for Spinal Cord Stimulator (SCS) placement. Fellows will participate in a weekly skills group for pain, as well as contribute to the quarterly Pain Neuroscience course delivered in collaboration with the physiatry and physical therapy specialties. Fellows may also have the chance to participate in research activities related to this course.

Sleep Medicine (4 months)

The Yale Sleep Medicine Center evaluates and treats patients with sleep disorders and sleep-related conditions. Accredited by the American Academy of Sleep Medicine, the sleep medicine program offers a coordinated approach to the management of a variety of sleep disorders and related conditions. The sleep medicine team includes physicians and psychologists boarded in sleep medicine in addition to other specialties such internal medicine, pulmonary disease, neurology and pediatrics.

Within the Sleep Medicine Program, fellows work closely with a board-certified sleep psychologist and within a multidisciplinary team while receiving advanced training in cognitive-behavioral therapy for insomnia (CBTI), an evidence-based treatment for insomnia that is the practice standard. Fellows also receive training in the evaluation and cognitive-behavioral treatment of other sleep-related disorders such as circadian rhythm disorders, narcolepsy, night eating syndrome and parasomnias. Behavioral sleep methods are also used to increase CPAP adherence for patients with obstructive sleep apnea. Fellows review sleep studies and learn about pharmacological ways to manage sleep disorders as well. They also participate in a half-day seminar and case conference sponsored by the Department of Pulmonary, Critical Care and Sleep Medicine and weekly Grand Rounds.

Tobacco Treatment (4 months)

The Tobacco Treatment Service provides tobacco use assessment and intervention for patients treated at Smilow Cancer Hospital and Smilow-affiliated community-based Care Centers across CT, as well as patients referred from the rest of the Yale-New Haven Health System. The Service comprises a multidisciplinary team of psychologists, physicians, advanced practice nurses, tobacco treatment specialists, and clinical research staff and provides care that is integrated with patients’ oncology/medical treatments. Patients receive evidence-based pharmacological and behavioral tobacco interventions either in-person or via telemedicine. Care is predominantly outpatient, but there are opportunities to provide inpatient tobacco use consultations.

Given the changing landscape of tobacco use, the Service now treats an increasing number of patients, both adolescents and adults, for vaping and other tobacco product use besides combustible cigarettes. Moreover, patients who are not interested in quitting are advised of tobacco harm reduction options (e.g., switching from combustible cigarettes to a tobacco product lower on the harm continuum such as e-cigarettes).

The Service supports a number of clinical research projects including an NCI-funded clinical trial of a presurgical smoking cessation intervention for patients with cancer or suspected cancer of smoking cessation interventions for individuals at high-risk for lung cancer and a trial of varenicline for e-cigarette cessation being conducted through the Service. Fellows can be trained in the delivery of manualized behavioral interventions for clinical trials. The Service participates in ongoing research activities stemming from the NCI Cancer Center Cessation Initiative (C3i) and has close collaborations with the Yale Tobacco Center for Regulatory Science (TCORS).

Within the Tobacco Treatment Service, fellows work closely with the Director, a psychologist, to receive specialized training in motivational interviewing/ enhancement techniques and cognitive-behavioral interventions to promote tobacco behavior change. They also learn about evidence-based tobacco pharmacotherapies and how to address medication misperceptions and promote medication adherence. Fellows participate in weekly Tobacco Treatment service rounds. Fellows may also have the chance to participate in research activities conducted through the Service, either by serving as a study therapist or collaborating on scholarly projects.

Evidence-Based Practices

The following evidence-based practices (EBPs) are used in this placement setting. Fellows generally have exposure to most of these EBPs though do not necessarily receive training or supervised experience in all of them. The EBPs include: Acceptance and Commitment Therapy, Cognitive Behavioral Therapy, Cognitive Behavioral Therapy for Insomnia, Cognitive Behavioral Stress Management and Relaxation Training, Dialectical Behavior Therapy, Dignity Therapy, Gut-Directed Hypnosis, Meaning Centered Psychotherapy, Mindfulness-Based Cognitive Therapy, Motivational Interviewing and Motivational Enhancement Therapy.

Psychological Assessment

Behavioral Medicine fellows conduct a variety of brief and (in some cases) comprehensive psychological and neurocognitive assessments during the year. Assessments are typically conducted within the fellow’s primary or secondary rotation, and involve the administration, scoring and interpretation of brief symptom or problem-based assessments. Assessments may also include evaluations of neurocognitive functioning and may also include the evaluation of presurgical candidates within cardiovascular, transplant, and pain services.

Diversity

At Yale-New Haven Hospital diversity and inclusion are important components of its organizational values. The hospital is committed to providing an environment of inclusion that supports the diversity of its patients, visitors, employees, business partners and communities. Serving the Greater New Haven area and surrounding Southern New England region, YNHH admits a diverse population of patients, both diagnostically as well as demographically. Racially, approximately 65 percent of patients admitted to the hospital are Caucasian, 15 percent Black, 15 percent Hispanic and 5 percent Asian. Nearly 60 percent of patient’s hospital costs are paid for through Medicare or Medicaid. The hospital is committed to providing the highest standard of care to all patients regardless of socioeconomic status, race, ethnicity, language, nationality, sex, gender identity, sexual orientation, religion, geography, disability and age.

Research and Scholarly Activity

The Yale School of Medicine ranks 4th overall in the U.S. for research dollars awarded by the National Institutes of Health and 1st for Psychiatry. As such, a core feature of the internship is to provide advanced research training to help fellows enhance their skills in conducting patient outcomes research, implementing research projects in applied settings, and designing and testing novel health psychology interventions.

Fellows have a minimum of four hours per week of protected time to design and conduct a scholarly project of their choice in collaboration with the primary advisor, and/or another faculty mentor involved in a program of active research. Fellows may design a project with faculty within their primary training placement, or request to be matched with other Yale faculty based on their shared interests and faculty availability. The fellow’s scholarly activity can take many forms such as analyzing data from a completed or ongoing research project, evaluating a clinical service or program, or helping design and implement a new project that will benefit the individuals receiving services within the YNHH system. Fellows are encouraged to select a project that can be submitted as an abstract for a local/national conference and/or manuscript.

Past faculty mentors include Behavioral Medicine faculty as well as other faculty across Yale (e.g., Robert Kerns, Nancy Redeker, Tish Knobf, Michael Hoge, Kathy Carroll, Nancy Redeker, Ruth McCorkle).

Faculty

Dwain Fehon, Psy.D., Director, Behavioral Medicine, Site Supervisor, Palliative Care
Dana Cavallo, Ph.D., Site Supervisor, Pain Medicine
Lisa Fucito, Ph.D., Site Supervisor; Director, Tobacco Treatment
Alexandra Fuss, Ph.D., Site Supervisor, Digestive Health
Jennifer Kilkus, Ph.D., Site Supervisor, Psycho-oncology
Susan Rubman, Ph.D., Site Supervisor, Organ Transplant
Kim Smolderen, Ph.D., Site Supervisor, Cardiovascular Medicine
Lynelle Schneeberg, Psy.D., Site Supervisor, Sleep Center
Kathi Croce, Ph.D., Voluntary Faculty Clinical Supervisor
Anne Dutton, LCSW, Voluntary Faculty Mindfulness Supervisor
Amit Oren, Ph.D., Voluntary Faculty Clinical Supervisor

Supervision

Fellows receive, on average, at least four hours of supervision each week. Fellows have weekly individual supervision with their primary advisor, secondary advisor, and additional site supervisors, and outside voluntary faculty supervisors. Fellows also participate in a weekly Mindfulness group supervision meeting, and receive as-needed psychological assessment supervision. Formal evaluations of the fellow’s performance are completed three times a year that serve as opportunities to review progress on training goals and address progress toward mastering core competencies.

Formal evaluations of the fellow’s performance are completed three times a year that serve as opportunities to review progress on training goals and address progress toward mastering core competencies.

Fellows may also be assigned the role of "peer supervisor" to junior trainees within the Behavioral Medicine placement. Typically, junior trainees are third- or fourth-year graduate students from regional doctoral psychology programs who are participating in clinical practicum placements at YNHH. As a "peer supervisor", fellows meet weekly with their supervisee and have the opportunity to develop basic skills as a clinical supervisor by processing this experience within the context of their own primary supervisory relationship.

Seminars and Specialized Training

Behavioral Medicine fellows attend and participate in the weekly core seminar held within the Department of Psychiatry, as well as separate weekly hospital-based seminars for fellows and other psychology trainees based at YNHH. In addition, Behavioral Medicine fellows participate in a Behavioral Medicine didactic seminar and have the opportunity to attend multidisciplinary seminars and case conferences with advanced psychiatry fellows, residents, and medical students within the Department of Psychiatry’s Consult Liaison Fellowship program. During their Sleep Medicine rotation, Behavioral Medicine fellows are also able to interact with advanced fellows in pulmonary, critical care, cardiovascular and sleep medicine and attend the weekly State Sleep Conference (State of the Art in Sleep Medicine), Research in Progress Sleep Medicine meetings, Sleep Journal Club, Vascular Medicine Outcomes Research meetings, and other special events such as the annual Sleep Research Symposium.

Numerous additional didactic health and medicine related case conferences, seminars, and grand rounds are offered through the Yale-New Haven Transplantation Center, Yale Cancer Center, and Yale School of Medicine. Participation in these optional activities is at the discretion of the fellow and their primary advisor as schedules permit.

Applicant Qualifications

Strong applicants for this placement generally have prior experience working within medical settings with individuals diagnosed with serious or chronic medical illness, and/or working with individuals on lifestyle and health behaviors that negatively affect health. These applicants will also have experience conducting evidence-based therapies (e.g., cognitive behavior therapy) and have some basic experience with neuropsychological assessment. Fellows who match with this placement typically have a strong interest in the provision of clinical care and/or scholarship related to behavioral medicine or clinical health psychology and show promise for developing into leadership roles.

Applicants selected for this placement must successfully pass background checks conducted by Yale University and Yale-New Haven Hospital.

For Further Information

For more information about this placement site, please e-mail dwain.fehon@yale.edu.