This week we talked with Dr. Marshall Seligmann. He’s a pediatrician who also has his feet in technologies and startups. He studied psychology in college so he’s a great person for us to interview because he can teach pediatricians and parents about the behavioral medical issues we see in kids.
Hi Marshall. Can you tell everyone a little about your work?
I am a Pediatric Urgent Care specialist. I did my undergraduate at Boston University, where I studied psychology. I went to medical school at SUNY in Brooklyn and did my residency at Children’s Hospital Los Angeles – and have stayed out here ever since.
You’re a doctor and studied psychology. This blog is all about teaching psychology and how to apply it in life and work. What role does psychology play in your day to day work?
You see a lot of things like defense mechanisms, behavioral issues, particularly on the parenting side. A lot of the health benefits we try and promote come from changes in lifestyle and behavior.
Why do kids come into you typically for pediatric urgent care?
In urgent care, it’s usually for urgent issues like bloody noses, fevers, colds, sprains, broken bones, and the like. In the urgent care setting, I don’t do as much related to psychology, but I also do some well child visits and that’s where psychology plays more of a role. Well-child visits are regular check ups, where you really get into discussions of behavior and lifestyle (diet, exercise, BMI).
What are the biggest problems you see in kid’s behavior? What are children not doing that would be good for their health?
Everybody can improve their diet. There is way too much unhealthy snacking and unhealthy drinks and lots of excessive sugar intake. I counsel parents and kids on things they can change in their diets that will make a big impact on their overall health. I also recommend exercise regimens and strategies to implement those on a regular basis. I try to do motivational interviews with kids for behavior change, when I can.
Regarding behavior change, what do physicians typically learn about behavioral change and incorporating these techniques into helping kids get healthier?
One thing we learn is not to try and change too much at once. If you have a child who is overweight, and you try to get them to change their entire diet and exercise schedule all at once, it’s not something people can adapt to easily. One technique is to see these kids regularly, you discuss one small change that they can make, for instance – getting rid of sweet drinks or soda in the diet. Then, in a month, you discuss that specific change.
We are taught to use motivational interviewing, which is a method of assessing how ready people are to make those kinds of changes in their life. If someone is in a stage of pre-contemplation, where they never thought about making any of these types of changes, then the focus of that visit will be bringing some awareness to the problem so that they are aware of the issue at hand but not trying to make big changes, just trying to get them to recognize that there is an issue.
If they have thought about it already, but haven’t taken any steps towards making changes, then you discuss what they have thought about, what they can do to make those sorts of changes. If someone has already taken some steps, then you can congratulate them on taking those steps and plan for next steps and discuss barriers.
You mention the stages of change model and precontemplation. Is that something that physicians and, specifically, pediatricians are trained to use? What other models or ideas from psychology are being applied on how to change kids’ behavior?
Motivational interviewing, which is looking at the different stages of readiness, that is the big one that physicians are taught. For example, at Kaiser they have a specific weight loss program for teenagers, where the main focus is motivational interviewing. This is a widely used technique.
If you haven’t discussed how to get barriers to change out of the way, it’s very difficult for people to make those changes using willpower alone. If I want someone to stop eating chips, for example, I don’t simply say, “stop eating chips, they’re bad for you.” They know that. The key is to identify the reason they’re eating chips so often. Usually, it’s because it’s just readily available in the house to consume.
So, rather than get someone to exercise more willpower, you try and make an environmental change – to remove that element from the equation. Remove the chips from the household, for example, and that is a change you can make. That level of change is a concrete thing people can focus on changing, rather than giving a more general instruction like “eat healthier”. Same with exercise, if you say “exercise for 30 minutes each day” that will seem like an insurmountable task, so you find smaller tasks like, take the stairs instead of taking the elevator. Start with small steps, and progress over time to achieve a goal rather than setting the goal as the change itself.
Aside from that, we are taught different interviewing techniques for how to talk to patients and how to gently broach topics, how to change topics. For instance, if someone comes in for an earache, but they also mention that they watch TV four hours each day, you can transition gently in a way that is not jarring for the patient, so you can discuss sensitive issues in the context of a short period of time without it being overly invasive or disorienting.
Is psychology incorporated into medical training, residency or fellowship?
There was some teaching, but not really a lot. I have a background in psychology from undergraduate. You do a psychiatry rotation in medical school, but that’s usually focused on in-patient psychiatric conditions (bipolar disorder, schizophrenia). The psychology training, for the most part, is something that is not well-addressed in the curriculum. We did learn motivational interviewing in residency, and they do teach you how to deliver bad news as a medical student, but it’s a sort of cursory introduction to the psychological concepts. They rely on you just going out and practicing on the job, finding techniques that work for you – which is probably not the most optimal way to do it.
What do you think is the role of the physician in pediatrics? Is it to help kids to stop eating junk food? Is it medicine? What is the role of the pediatrician now and in the future?
Behavior is definitely tied into overall health, and as a pediatrician, if you can identify behaviors that are impacting a patient’s health, your role is to provide some sort of counseling and recommendations for changes. That being said, the pediatrician’s office, the way it is set up, it is not the ideal environment to provide psychological counseling or therapy. It is mainly set up to detect problems, for instance, to screen for drug addiction, or attention deficit disorder. In terms of the actual counseling, that’s usually relegated to behavioral therapists, psychologists, psychiatrists. Depending on the practice, some pediatricians prescribe some psychoactive treatment. More and more, as medicine is becoming specialized, pediatricians are focused on providing medical care alone and referring out for psychological issues.
There are some practices where I have prescribed ADHD or depression drugs, but those are usually in settings where I do not have easy access to a psychologist or behavioral therapist. If I do, then it’s usually much better for the patient to see those people in conjunction with their general pediatrician.
How do you think pediatrics and the practice of medicine will change in the future with technologies, apps, and companies that request home visits from physicians? Will this approach of referring out to other shift?
The nature of medicine has changed and will continue to change but as medicine becomes more complex, as our understanding of various subspecialties increases and becomes more specialized, it becomes more difficult for the general practitioner to have an understanding or enough expertise to treat specialized conditions. The current model, where you have specialists seeing patients for specialized conditions, will stay.
Doing home visits is actually an old practice that is being revitalized with new technology – I just started with a company called Heal that’s doing this. You’re still providing the same services that you would be providing in the general pediatrician’s office.
In terms of referrals, you can refer the same way from a home visit as from an office visit. It will be exciting when you can get home visits from specialists as well. There are certainly no barriers for home visits from psychology and psychiatry. Telemedicine, with face to face video conferencing with patients or consultation with specialists also opens up access to more patients who previously may have been geographically limited. Bringing the physician into the home will happen more, and we will see more general practices adopting and more insurance companies reimbursing for it.