Changing Face of Medical Care

 

There is change mentioned at every lecture I attend, every lunch time discussion, every committee meeting. I hear these discussions in primary care and in psychiatry, but I think it is likely that every corner of health care is struck by the feeling that we have reached a pivot point. Today’s angle was delivered from an esteemed Duke primary care physician, director of the Family Medicine Residency, and a former student. Family Medicine, he says, will no longer focus on why patient A does not take his blood pressure medication, but the physician will look at a bigger picture of how can he/she implement a system which facilitates compliance. We changed the name from compliance to adherence and back to compliance, but that is another story. This system is going to involve using technology, nursing and administrative staffs, wellness groups and community outreach. It sounds like Kaiser to me. In fact, it is the Kaiser model. Have lesser trained folks work on the patient interface, while the physician does what he is trained to do; decide what the problem is and how to treat it. After that, the can gets kicked down the road, and the health care team deals with the details of implementation. Theoretically, this makes a lot of sense. Practically, Kaiser, as the model, does a good job, mostly. My issue, as my readers have heard before, is that the reward system for the physician has changed drastically. It used to be that the implementation of the details, understanding why patient A does not want to take his medication, his resistance, if you will, to making his life better, was where the deep relationship developed, and hence the career satisfaction. Now, unless a physician “goes concierge,’ as my colleagues like to say, that connection is lost, leading to a more technical job of diagnosis and treatment recommendations. More technical means that patients, on average, will get good care, but the physician will only be using his left brain. The integration of the right brain, the understanding of how human emotion interfaces with disease management, will no longer be in the physician’s scope. As a policy maker, this makes sense. As a physician, well, the world is changing.

Graduation Time

 

Tonight the UCLA Child Psychiatrists are marking the end of their fourteen year journey to professionalism. There are eight 30ish men and women who will begin careers for the first time, without the mandatory supervision of faculty members. Many folks see this as a prolonged adolescence in that despite their age, they have yet to experience the responsibilities of adulthood. Although they are licensed physicians, and perhaps board certified in adult psychiatry, they have never had the experience of being an employee. Thus far, they have been in this in-between land in which they are working under supervision, similar to an apprentice, while still learning their trade. They are graduating at a time in which the Affordable Care Act will soon change the landscape of medical practice. Access to mental health care will explode, leading to a high demand, but at the same time, the providers of this care will likely be primary care physicians and nurse practitioners. Psychiatrists, the experts project, will be consultants, helping those on the front lines deal with the issues of mental distress. Yet, their training has not been embedded in primary care so the jobs they jump into will not resemble their apprenticeship. This reminds me of my training where psychotropic medications were yet to explode, so I launched into a world of “psychopharmacologists” thinking that word was for those with PhDs in psychopharmacology and not clinicians. As I have often said in these posts, I was caught in a world in which my younger colleagues became great enthusiasts for the wonders of medication, whereas  my older colleagues had deep skepticism, and I could see both sides. This is the dynamics of medical training, where the embryonic development is so long, that the field one enters is not the field one exits. Excitement and apprehension ensue. These folks have had multiple graduations, from college, medical school and residencies, but “this is the one that matters” I tell my students. “This graduation means you are entering into a world in which you are now responsible for your own career.” I say, remembering the weight of this crossroads.

The Joys of Medicine

Leadership

Fungible

 

Health care is moving to assembly line medicine which means that physicians are completely interchangeable, or fungible, entities. This does not mean that people will get poor care, but it does mean that the role of the physician has changed from cultivating relationships to following algorithms. In the long run, those attracted to a medical career will be a different personality type than those in the past, as following algorithms is a different skill set than feeling the pleasure of healing relationships. I understand the value of fungibility, yet I am sad about this change.  Adapt or die, comes to mind, and so I will adapt.

 

 

 

 

Fungibility is the property of a good or a commodity whose individual units are capable of mutual substitution, such as crude oil, shares in a company, bonds, precious metals, or currencies.

It refers only to the equivalence of each unit of a commodity with other units of the same commodity. Fungibility does not describe or relate to any exchange of one commodity for some other, different commodity.

As an example: if Alice lends Bob a $10 bill, she does not care if she is repaid with the same $10 bill, two $5 bills, a $5 bill and five $1 bills or bunch of coins that total $10 as currency is fungible. However, if Bob borrows Alice’s car she will most likely be upset if Bob returns a different vehicle–even a vehicle that is the same make and model–as automobiles are not fungible with respect to ownership. However, gasoline is fungible and though Alice may have a preference for a particular brand and grade of gasoline, her primary concern may be that the level of fuel be the same (or more) as it was when she lent the vehicle to Bob.

 

http://en.wikipedia.org/wiki/Fungibility

 

 

Women Doctors

Last night I had the privilege of speaking to a group of women physicians, mostly psychiatrists, leading to the inevitable topic of how quickly the field of medicine is changing in that it is unrecognizable from our field twenty years ago. We were middle-aged women who remember when it was a big deal for a woman to become a physician; gender atypical, one might say. Now, over half of most medical students are women. As a group, our daughters, not our sons, are entering medical training. “What does this mean?” one woman asked. “Women will earn the money and men will take care of the household,” one woman answered. “Or women will do both, like they have been doing for generations,” another woman said. “Women are twice as likely to get depressed as men,” I say, adding in a well-established psychiatric statistic. “Is this related?” I ask out loud. “Yes, but women are twice as likely to get depressed from menarche to menopause, so that makes it seem hormonal,” one knowledgeable woman answered. “Yes, but those are also the years where women have to juggle a lot of competing responsibilities,” another well-informed woman chimed in. “Men are more likely to be alcoholics,” another woman said, implying that maybe men deal with their psychological issues through substances and not through talking about their mental state. As usual, we had no answers, but many questions. Our worlds,  the world of knowing a “woman’s role” and the world of medical practice, is confusing to us. We want to help people, but how best to do this, is not completely clear. We want to be role models to our younger colleagues, but we do not understand their world and they do not understand ours. All in all, it was nice to be together to chat about common concerns. My job was to keep the conversation going. They did not need me for that. The passion for this topic generated the energy in the room.

Tele-Psychiatry for Kids?

At the risk of sounding like an old fart, I am not prepared to accept the changing nature of psychiatry, yet again! For many years, I have appreciated the advancement in technology leading to Tele-Psychiatry, where people who cannot leave their homes, or who live far away, can connect remotely to a psychiatrist, allowing for access which would otherwise be impossible.  For adult patients, I am excited by expansion of our services. Now, let’s move into Child Psychiatry. Can a Child Psychiatrist do an assessment through a computer screen? It seems to me that evaluating children, working with families, mandates a three-dimensional exposure which would be severely limited by Tele-Psychiatry. As so much interaction is non-verbal, and as so much of an assessment includes “playing” with the child, I do not see how remote communication can simulate this encounter. Two-way communication devices are wonderful advances in medical settings where doctors do not need to touch their patients, but as a Child Psychiatrist, the “touching,” or more specifically, the shared use of space is critical to understanding how a child navigates their world. Some kids come and sit quietly, whereas other kids have a hard time staying still. Sometimes my words help kids focus, whereas other times, a child needs to be active in my office. These nuances will be lost with a remote access device. Once again, I am left thinking that change can be good, but then again, not always. I understand the dilemma between improving access and quality assessments. I also understand that as a field Psychiatry, particularly, Child Psychiatry, has to hold on to the key tenets of the profession. For me, this includes being in the physical presence of a family is an important component to the understanding of powerful relationships and their sequelae. I am not sure I would be willing to compromise on that issue. Technology should aid us in our goals, not detract us from them. Tele-Psychiatry for kids seems to move my field in the wrong direction.

The Embedded Psychiatrist

Oh, no. Psychiatry is heading towards another turn and once again, I am deeply concerned. As I understand the future of psychiatry, according to my highly respected colleagues, is that psychiatrists are now going to be ”embedded” in primary care offices where they may or may not see the patient, but they will consult on the diagnosis and psychopharmacological intervention for patients that are seen by nurse practitioners and primary care physicians. Now, understand, that I work in primary care, and I am a strong advocate that primary care physicians should have psychiatrists to consult with on their cases, but this does not mean that the psychiatrist should not have the ability and skill set associated with deep listening to patients and understanding the nuances of a good evaluation. My concern is that the psychiatrists of tomorrow will help primary care physicians prescribe psychotropics, without developing the tools of listening to patients and having continuity with patients. Psychiatrists will mostly be trained to consult, without having direct patient care responsibilities. Once again, this will change the field, both in terms of how it is practice, and in terms of who is attracted to this kind of work. In essence, the doctor/patient relationship, the most valued aspect of the treatment, will disappear from the field of psychiatry. I have previously posted about the development of a psychiatrist, strictly as a psychopharmacologist, has minimized the doctor/patient relationship, but this new development, where the psychiatrist is strictly a consultant, takes my issue into a deeper concern. I wonder if history taking and relationship building will be a lost art in medicine. I certainly hope not.

 

See also…http://shirahvollmermd.wordpress.com/2010/11/08/patient-centered-medical-home/

Going Global

Education is global, like all other industries these days. Medical schools are having training programs around the world. Exchanging information, exchanging students, a long-time practice of college education is now expanding to graduate schools and post-graduate education. UCLA Medical School are now setting up guidelines for their world-wide electives. Cornell Medical School has started a “branch” in Qatar. Two UCLA Child Psychiatry fellows are off to India to explore child mental health in a rural area. Some UCLA Family Medicine Residents ventured off to Haiti after the earthquake to help with the pressing medical needs of the distraught population. This, strikes me, as a new and exciting expansion of medical education. In my day, it was the rare soul who ventured out of the country to explore how medical care is administered in different health care systems. Sure, we were allowed, maybe even encouraged to do electives at other US medical schools, but we were never supported to go beyond our borders. I suspect that this relatively new development goes along with our increase in connectivity and thereby the increase in cross-fertilization. It is wonderful to think that our next generation of physicians will have a broader world view. It is also wonderful, selfishly speaking, to think that there might be opportunities for teaching around the world. Teaching and learning always go together. Global teaching and learning seems so rich and vibrant with new ways of thinking about how to help people. For example, European physicians write prescriptions for spa treatments as a way to help those in mental distress. I think that is brilliant. Trite but true-the world has so much to offer.

 

See also….http://shirahvollmermd.wordpress.com/2012/08/21/calling-my-266-german-friends/

A Concierge Psychiatrist?

Are psychiatrists going concierge? Wait, I am confused. I understand that certain primary care physicians charge patients an annual fee to be on their patient panel. In exchange for this annual fee, the patient is given more personalized service including easy access to their physician, house calls and sometimes the physician goes with the patient to their specialist. This means that the primary care physician goes from a panel of patients in the thousands to a number which is less than one hundred. The ethical dilemma is who is going to take care of the patients who are no longer seen by primary care doctors who change their practice. There is a primary care physician shortage, but whose job is it to fill in that gap? Is that the doctor’s responsibility? I recognize the dilemma both for patients and for physicians over this trend to pay for more personalized service. Now, let’s add-on. Are psychiatrists now charging patients a retainer to be on their panel? Does this make sense? Maybe. Maybe not. Fees are interesting therapeutic issues. When people pay do they value the service more? Sometimes. On the other hand, paying for service could make them value it less, as some people see financial exchange for immediate service as a right, without an appreciation for the  effort that goes in to accommodating other people. There are a limited number of hours in a day, so one has to limit the time or limit the patients somehow. What is the fairest way to do this? Maybe fair is not relevant here. Maybe this is a personal choice, where physicians choose how they practice and patients choose what makes sense for them. On the other hand, maybe there should be public service requirements of physicians, where they have to spend some time serving a low income population in order to maintain their license? Maybe The Medical Board should require physicians to teach in medical schools as a way to spread their knowledge and experience. I have no answers-just questions.

See also…http://www.latimes.com/news/local/la-me-concierge-medicine-20120729,0,269142.story

http://www.youtube.com/watch?feature=player_embedded&v=8IX-zdZdOco