Shirah Vollmer MD

The Musings of Dr. Vollmer

Is Bad Care Better Than No Care?

Posted by Dr. Vollmer on January 28, 2015

 

If the choice is bad care or no care, what do we choose? This sums up my current focus on the changing nature of mental health delivery. Today I am reminded that psychiatrists are asked to do paper reviews of prescribing practices. This means that there will be psychiatrists employed to review charts to determine the kind of care the patient needs. Whatever is documented is valued as being “true” since the psychiatrists will never interview the patient, and in terms of children, he/she will not interview the parents either. Like teachers who are forced to teach to a test, rather than help each child learn to the best of his ability, physicians are now looking at data, and this data is what is entered into the computer, and this data is used to evaluate the appropriateness of the care. Garbage in, garbage out, as computer engineers would say. We rely on the input to make determinations, but we are not questioning the input. This results in big data which is determining reimbursement and program development. Measuring cholesterol may help determine the overall health of a population, but there is no corresponding measure in psychiatry. There is no short-cut for assessing mental health. The long-cut is a trained professional doing a painstaking interview, along with review of previous evaluations, talking to collateral historians and then formulating a hypothesis which is tested over time, through interventions such as psychopharmacology, psychotherapy, and environmental manipulations. This is my rant. I will keep saying it, as long as I keep hearing about the future of medical care, and in particular, the future of mental health intervention. Bad care is not necessarily better than no care, but bad care breeds statistics and big data. No care seems like neglect, but picking an option which only gives data, but does not address the state of mental health assessment is not wise.  “There is no money” I keep hearing as to why the system is stuck. “You mean that it is not a priority,”  I reply. And so the dilemma continues.

6 Responses to “Is Bad Care Better Than No Care?”

  1. Ashana M said

    If the care makes you sick, then it is not better to have it. Substandard care? Oh yes, much better than no care. I have relied on substandard medical for a year now and believe me, it is much better than no care.

    Data keeps people honest. That’s why we use it. While it’s silly to teach to a test, when we tried to help children learn to the best of their ability, middle-class or wealthy, white children with educated parents somehow had much more innate ability than everyone else. As a system, no accountability for results perpetuates unfairness. There is a reason we need objective benchmarks to measure the effectiveness of medications, teaching strategies, and psychotherapy. Without data, we pat ourselves on the back, think we’re doing a great job, and repeatedly fail our clientele without ever noticing or striving to improve the system.

    No, there’s not enough money, because we are too psychologically sickly as a society to afford all the mental health care we would need if it could only be provided by doctors. Part of our cultural knowledge needs to be how to be well, so that every fifth person doesn’t need specialized medical care for mental health at any given time, and that level of care can be dedicated to people who genuinely have very complex needs. With our current system, it’s as though everyone with a cold needs to see a specialist, and the ones who do get care are not the sickest but the wealthiest. It’s absurd. It’s not that our mental distress is not real or important, but at some point we need to look around and wonder why exactly so many of us are so distressed so much of the time.

    • Hi Ashana,
      I see your points clearly. The question is whether what applies to general medical care also applies to mental health care. Maybe substandard care is better than no care, and yes, data is important, and yes, health care disparities exist, but in the mental health arena, mining data may be only way to evaluate impact. Thanks.

  2. Shelly said

    I can see how you would say that the role which you and other professionals like you are forced to play are very, very limited by what has been documented. As you say, “Garbage in, garbage out.” Is it possible to request that the providers interview the family members and document the results so that you can evaluate it as well? Couldn’t you see it as a paralegal putting together all of the paperwork for the attorney…your mental health team doing all the legwork for you and you seeing the package at the end? This team could be made up of social workers, therapists, and other lay people with you guiding them as to your needs so that you have the complete picture to make a work plan with the patient at the end of the day.

    • Yes, what you say makes a lot of sense. If there are qualified professionals doing the leg work, then the system could work well. The problem is that the focus is what is inputed into the computer and NOT what the patient says. Quality measures are looked at through metrics. For example, if a child is on 5 meds then that will be flagged as bad care, whereas if they are on 4 meds, then that is OK. Well, now I can imagine that most kids in foster care or the juvenile justice system will be on 4 meds so their charts will not get flagged. This makes no sense to me. Thanks.

  3. Eleanor said

    Hmmm….mental health treatments…bad care or no care…speaking personally I would choose the latter. I waited too many years after my daughter was born with severe physical disabilities to seek therapy tho I knew we both needed it big time. I was terrified of “bad or irresponsible” care. I didn’t know where to look, what questions to ask, what qualifications, degrees, training…..MD or psychologist, opinions of colleagues and qualifications of those who offer references, therapeutic approach….psychodynamic or short term….etc etc etc. Now I know what to look for but most folks don’t….and it’s not getting any easier in our fast paced digital world of quick fixes and superficial approaches. Again, my opinion but in mental health there is danger in the wrong type of treatment by a therapist not versed in the depth and layered complexity of the human mind.

    • Yes, it is not an easy question. As I have said, the focus is on metrics, so if they enroll a lot of people in a mental health program, regardless of the quality of that program, then the report will say that mental health treatment has expanded. Since mental health is so hard to measure they will look at questionaires which are either filled out by the practioner or the patient, both of which are subject to bias and misrepresentation. I prefer that we look at outcomes such as homelessness, since getting people off the streets is a clear indication that society is improving. The studies there show that the best intervention for homelessness is to provide housing. This, although obvious, seems better than working with the individual to get a job and “get back on his feet”. http://www.newyorker.com/magazine/2014/09/22/home-free Thanks!

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