Shirah Vollmer MD

The Musings of Dr. Vollmer

Integrated Care: I Don’t Think So

Posted by Dr. Vollmer on November 19, 2015

Training primary care physicians to manage mental health problems is now termed “integrated care,” a phrase I have come to associate with those fingers on a chalk board. In my old, pre-Prozac life, integrated care was a wonderful way of encouraging collaboration between mental health providers and bodily health providers. Communication facilitated a deeper understanding of the patient and that excitement brought me to the field of  psychiatry. Psychiatrists could share with primary care (we did not call them that then, they were internists or family practitioners), the issues the patient was struggling with, in broad confidential terms, while at the same time, primary care physicians could shed light on how their physical problems might be impacting their activities of daily living. This was, dare I say, the “good ole’ days.” Now, however, integrated care means that the psychiatrist does “chart review” and based on the electronic medical record (which tends to have a minimal narrative) offers suggestion for treatment. Oh my, the history taking skills of a psychiatrist are once again, no longer valued, or needed. In fact, the psychiatrist is seen as the physician who offers the “magic potion” which will elevate the patient away from his suffering, all without ever making eye contact with the patient. The primary care physician makes the eye contact, but not really, since he/she is buried in making sure the electronic record is filed and hence his eyes are often on the computer, and maybe for a few minutes on the patient. Yes, the upside of this paradigm is that more people will have mental health services, but that brings us back to the question of whether bad care is better than no care? However, for the moment, I am not focused on the patient care aspect of this paradigm, but rather I am focused on the job satisfaction of the psychiatrist. How do you feel pleasure from suggesting a medication, when in fact, there are no “magic bullets,” but rather a journey, or as Yalom says, a “fellow traveler” aspect to healing. Psychopharmacological intervention needs to be woven into that journey, rather than extracted as a separate avenue. In my mind, integrated care means integrating medication into psychotherapy, rather than integrating medication into a seven minute primary care visit. So, I am all for a comprehensive approach to mental health care, one that integrates body and mind, but doing this with limited time, simply makes no sense.

4 Responses to “Integrated Care: I Don’t Think So”

  1. Shelly said

    I hear you. Today, the internist can prescribe anti-depressants after listening to a patient for 5 minutes and then the patient never needs to ever see a psychiatrist. The patient might develop side-effects, and then the internist handles the side-effects too. Anything stronger than the prescribed dose, though, the internist sends off to the psychiatrist, because the family doctor doesn’t feel confident handling prescriptions outside their comfort zone. Rarely do the psychiatrist and family doctor talk and consult about the patient (at least where I live). So now there are then three people in “the journey, but it’s really two professionals working in parallel with the patient but not interacting with each other.

  2. Laura said

    I think the integrative model can work in psychiatry but the system needs to be flexible enough to handle the outliers of those that don’t fit the model.Unfortunately often the systems that get put into place are not flexible. I have seen very mentally ill patients get terminated because they did not fit the ‘model.’ I’m talking teenager with addiction, psychotic with possible weapon. That was at a state funded community mental health center. It did not go over too well when I replied it was time they changed their model.

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