Integrated Care: I Don’t Think So

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.

How Does A Medical Student Choose A Specialty?

How Important Is A Diagnosis?

Who can/should diagnose a psychiatric illness and after all, why is this necessary? The latter is easy to understand. Without a proper diagnosis, there cannot be the appropriate intervention. Yet, is psychiatry that simple? Of course  not. Many therapists do not think in terms of diagnosis, but rather in terms of psychic pain, and as such, they try to alleviate suffering, without too much concern for the category of illness. Sure, a diagnosis has to be written on an insurance claim form, but “depression” seems to serve that purpose for almost all. Yet, what if they miss something? What if they think someone is schizophrenic, when, in fact, they are looking at a drug-induced psychosis? What if they miss that someone’s enthusiasm, is really mania, requiring immediate intervention? What if the person needs to be treated against their will, and yet the therapist is mostly comfortable dealing with patients who consent? What about primary care physicians, who are becoming more and more responsible for managing mental illness? How much training do they get? Who trains them? Do they know when they have hit their limits, or does tragedy ensue? What about psychiatrists who attempt to train primary care physicians, or non-MD mental health professionals how to recognize serious mental illness? Are they adding to the problem of mis-diagnosis or are they part of the solution to help more of the mentally ill have access to care? If a middle-aged female is suffering because her husband left her for a younger woman, does she need to be seen by a psychiatrist, when the cause of her suffering appears to be straight-forward? Should she be triaged before being sent off to a therapist, or should she self-refer to a clinician she heard was good from her neighbor? That psychiatrists, through refined listening skills, and thorough history taking, can come to a diagnosis, is yet another skill set which seems to be trivialized and devalued. Systems of care look to psychiatrists to prescribe, but not to diagnose. “This person needs meds,” is often the reason for referral, as opposed to “this person needs an assessment.” Looking for an assessment is looking for a deeper understanding of the patient, whereas looking for “meds” is looking for the patient to be contained so the psychotherapy can proceed. Once again, it is clear to me, that with the excitement of our psychopharmacology boom of the early 1990’s, we lost sight of how valuable our diagnostic skills are. We neglected to trumpet that clinicians need to refer to us to help them understand what is going on, and not necessarily to prescribe medication. This nuanced issue is how we lost our way. We offer the mentally ill understanding, in ways that other clinicians, because of their limited training, cannot. We have been through medical school, learning pharmacology, physiology, anatomy and the pathophysiology of disease. We have been through residencies where we spent years in mental hospitals, working with the chronically mentally ill, day in and day out. We have worked in emergency rooms with violent and non-consenting patients, who are both frightened and frightening. We have worked in medical hospitals with patients who have recently tried to harm themselves in drastic and terrifying ways. We have seen the suffering in families trying to deal with a mentally ill relative, with all of the frustrations and despair that go along with this illness. This training, unlike other clinicians, has given us a way to say to people with psychic troubles, that we have seen this before and we understand, even if we do not have the best tools to help them cope. Understanding, even under these dire circumstances goes a long, long way. I never tire of saying that. I taught medical students that yesterday, and in a way, they seemed to understand their training deficits, if they did not undertake a psychiatric residency. Group by group, post by post, I hope to continue on with this message.

Medical Students: What Do They Want To Know?

Below is my post from 2010 about my presentation to UCLA Medical Students in the Primary Care College. Today, I repeated my lecture on ‘Psychiatric Emergencies’ , with the addition of a narrative about the wonders, and not such wonders, in DSM 5. I changed my presentation style, but not my content. I moved my body in front of the podium. I walked up and down the aisles, making me feel like a rock star, moving into  my audience. I made eye contact with each student. Only one person fell asleep. This, being 2013, most of these students were female, young, and enthusiastic. I arrived an hour early, so I could hear the lecture before mine. I learned that the Affordable Care Act is going to focus on patient satisfaction, public health and cost-efficiency. As such, pediatricians will, in all likelihood, not do ‘well-child checks’ as this can be done by nurses. Pediatricians, like in many countries around the world, will be specialists, referred to after the Family Medicine doctor gets stuck. Most doctors will not be self-employed. They will work for large systems of care, like Kaiser. Specialists will have trouble finding jobs in areas they want, as they will need to be “deployed” to where the need is. Primary care will be in demand. Loan repayment was the largest area of discussion. Most students are saddled with large debt. The rate they pay it off, and the type of job they get are influenced by their tolerance to handle such demands. Once again, I found myself in a field that is rapidly changing, feeling like, although I sat in those same chairs, thirty years ago, I cannot connect with the experience of the current students. They are entering in a world which is evolving so quickly, that they do not know what their world will look like when they finish their training, five or seven or nine years from now.

There was then a ten minute break which, quite cleverly, I thought, the physician-coordinator, told us that it was time to do our exercises. All fifty of us got up to do a series of dance steps, swinging our arms and legs, while this physician reminded us that physical exercise will help us concentrate. She transformed from Professor to exercise guru. It was cool.

I began by asking how many students were interested in psychiatry. Three hands went up, but the coördinator reminded me, that primary care has a lot of psychiatry. Yep, I knew that. These are new fourth-year medical students, about to apply for the “match,” meaning they had to rank order their list of residency programs that they were interested in. This is a major crossroads in their lives, and although I don’t know these students intimately, most of them, seemed quite relaxed about their education and their future. I proceeded to talk about the management of a psychiatric emergency, reminding them that there are no objective tests, and so, all of psychiatry relies on informed intuition, based on a thorough history and good mental status examination. I talked about the importance of learning to listen to the patient’s narrative, as listening provides information for a diagnosis, but it is also therapeutic. I reminded them that psychoanalysis helps train people to listen, and so they could consider psychoanalytic training, regardless of what field of medicine they chose. One student after the class, told me they were indeed interested in psychoanalysis. I felt relieved. Listening is not dead in medicine, at least not completely dead.

 

 

From a Post Done on Wednesday, July 14, 2010

What is the Primary Care College?

UCLA School of Medicine: Fourth-year Colleges

Faculty members and students interested in common career activities are grouped into academic colleges during year four. The colleges are designed to

• strengthen career advising,
• improve the quality and selection of electives,
• provide a means of honing clinical skills,
• stimulate discussion of new findings in the basic, social, and clinical sciences relevant to the future practice of medicine.

College activities include an introductory course focused on advanced clinical skills and decision making, a monthly series of evening seminars, a longitudinal academic activity that can be either teaching or scholarship, and regular advisory meetings.

Academic Medicine — Careers that will include research or subspecialty training programs that require research. The theme is the development of skills in basic and clinical research.

Acute Care — Careers in emergency medicine, anesthesia, and critical care specialties. Themes include time-based decision making, physiologic correlations, and crisis management.

Applied Anatomy — Careers in the various surgical specialties, obstetrics & gynecology, radiology, radiation oncology, ophthalmology, and pathology. The unifying theme is anatomical implications in medical practice.

Primary Care — Careers in internal medicine, pediatrics, family medicine, obstetrics & gynecology, and psychiatry. Themes include prevention, mental health, international health, geriatrics, and women’s health.

Drew Urban Underserved — Members of this college are students in the combined UCLA/Drew University program, which is recognized for its placement of graduates in underserved communities.

Did Medicine Lose The Narrative?

Gene Beresin MD, Harvard Medical School faculty, wants to bring back the narrative to medical education. He made the point yesterday that coherent narratives help both patients understand themselves, and medical trainees understand their field. Narratives, he argued, creates attachment, and attachment creates security and comfort-crucial elements of a healing process. I am sorry, Dr. Beresin, as much as I fully support your mission, I am afraid that despite all of the advantages of electronic medical records, the major downside is the loss of the narrative. The stories are becoming much less important, replaced by symptom checklists and automated responses. I am not saying that medical care will get worse without the narrative, but I am saying that without the narrative, the practice of medicine changes its lure. Some folks,  like myself, are drawn to narratives. We love stories, be that in our patients, in books, in film or in theatre. The stories create a richness of life’s experiences which deepen one’s sense of oneself, as one begins to see a wider perspective of the world. So, maybe if I were coming of age today, I would be drawn to Eastern medicine, where the narrative still matters. Dr. Beresin, a man, I would guess, in his sixties, holds the old torch, making me nostalgic. He volunteered that he is also a musician, a man of the arts. That’s cool. Yet, despite his Ivy League credentials, I am afraid no mover or shaker in our health care system is going to listen. The value of the narrative is slipping away from the health sciences. It is too bad, but it is our future.

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.

SIG-E-CAPS

This is the mnemonic for diagnosing depression, according to our current manual, DSM-IV. Five symptoms, two weeks, seriously? Let’s review. Suicidal thoughts, are these active or passive? Perhaps they are related to a traumatic event. What if they go away in three weeks, then does the person still get a diagnosis of “Major Depression”. Interest in activities, is this losing interest or diminished interest? What if the person is fatigued, as a result of anemia, and this explains the lack of interest in activities? Guilt, my favorite criteria, since so much of guilt is unconscious, are we talking about conscious guilt? If so, very few people admit to this, particularly not int he first interview. Energy, see my comment on interest. Concentration, again, see my comment on interest. Appetite, decreased I can understand is a sign of mental dis-ease, but increased appetite is often a result of increased energy expenditure. Psychomotor changes, maybe a result of fatigue, or boredom, not necessarily depression. Sleep, same as appetite, in that it is often dependent on activity level.

So, am I dismissing our current diagnostic system? Yes and no. Symptoms must be taken in context. Context is understood through building a relationship where the patient increases trust, and therefore feels more free to display the context of his/her symptoms. A rush to judgment leads to a rush to medicate, leads to a patient not understanding his/her own mind. A delay in judgment could lead to needless suffering, but I would argue that the relationship building helps the suffering, so while I obtain a thorough history, I am also helping the patient symptomatically by providing a space for thought and reflection.

I want the patient’s history to become relevant again in psychiatry. This is a major reason I have this blog. I will repeat this point until my field changes its emphasis, or until I retire. I hope for the former.

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

‘Nonessential Medications:” Another Rant

Teaching Primary Care Residents, I learn so much. I also get frustrated, angry, and fantasize about going on the rooftops to let others know of my unhappiness. “Sometimes, when a patient comes in the hospital, and we are not sure what is going on, we stop the SSRIs and all the nonessential medications to see what is going on with the patient,” an excellent, smart, hard-working resident says to me. “Who says the SSRI is nonessential?” I ask, thinking that no one is checking in with the patient to see if he feels their SSRI is “nonessential”. “Well, you know, it is not life and death,” he says, understanding my discontent. “No, it is usually not life or death, but it is quality of life, and this can determine if the patient is motivated to help himself get better,” I say, knowing that the resident does not need an education about the importance of SSRIs, but that he is reflecting back to me the feelings of the team-the medicine team, composed of interns, residents and attendings. “I am sorry,” I say, “but I think that behavior suggests a dismissiveness to mental health. I think that the team is believing that SSRIs are relatively trivial medications and so they can be stopped, similar to vitamins.” He agrees, but looks at me with some sense of regret for bringing this to my attention because he can see my upset. I wonder how to push through this arrogance, sometimes seen in primary care, where they believe that physical health trumps mental health, every time, as if they are not closely linked. Medicine, as a field, has a lot of room for growth. Openness, as with all growth, has to be the first step. For now, I am stuck.