We spend so much more time talking about how to pay for health care
in the United States than we do wondering if what we get is worth what
we pay or how to make health care more cost-effective. My fields are
family medicine and psychiatry, and, to my chagrin, rarely do the two
specialties communicate. Here’s an example that cost the health care
system enormously. These kinds of situations arise commonly.
Recently a mother became concerned about her son who was feeling sad.
She talked to him enough to learn that he was being bullied at school
and that sometimes he wondered if it wouldn’t be better not to be here.
She took him to their family doctor who said he didn’t do mental health
and she would have to take her son to the emergency department at the
hospital so he could get services.
At first this sounds crazy, but in our health care systems, the
fastest way to get an appointment at the community mental health center
is to go to the emergency department. Otherwise, one waits months for
an appointment (at least where I work). It’s more questionable for the
family doctor to say, "I don’t do mental health.” We have extensively
training in handling mental health issues during our three year
residency. In Canada, where residency training is only 2 years, family
doctors are expected to manage all mental health issues with
psychiatrists available only as consultants, and actually do so.
So, the mother took her son to the emergency department. They waited
five hours to finally see a physician. He asked the son a few
questions. The coup de grace came when he asked the boy if he ever felt
as if it would be better if he were there. The boy agreed. Sometimes
he thought that way. The physician left the room for an hour and
returned to announce to the mother that he was transferring the boy to
the regional psychiatric center by ambulance, because of his suicidal
ideations. The mother objected. "I can take my son in our car to
somewhere else to be evaluated, just like I brought him here.” The
physician left the room and returned with a social worker and two
security guards who told the mother that she would be arrested and
detained if they interfered with the transfer of her son by ambulance
and that Child Protective Services would be involved because of her
failure to recognize the gravity of the situation and that her son
needed immediate treatment. She acquiesced and followed the ambulance
in her car. By now, her son was terrified.
At the Regional Psychiatric Center, they waited another 5 hours
before they saw a social worker who took the history. Then a physician
in training (called resident physician) came to talk to the boy and her.
After a total of eight hours at the Regional Psychiatric Center, they
were allowed to leave with a prescription for 5 mg of escitalopram, a
selective serotonin reuptake inhibitor (Brand name, Lexapro) and some
names of some private therapists to call in their home community.
Imagine the charges stacking up. The family doctor billed for an
office visit. The emergency department charged almost $2000 for their
evaluation. The Regional Psychiatric Center charged $2500 for their
evaluation. The ambulance transfer had cost $500. The prescription cost
At the Regional Psychiatric Center, the social worker and the
resident physician had managed to figure out that the child had no plan
to kill himself, but only sometimes wondered if it would be better to
cease to exist. In fact, until his encounter with the psychiatric
system, the child had not actually considered that people really killed
themselves. His concept had been more wistful and fanciful as he
wondered if it would be better not to exist. Presumably others have
wondered the same thing without benefit of Regional Psychiatric Care.
The mother’s observation was that each time she was transferred her
caregivers seemed younger and less experienced. At the same time, with
each transfer her son was becoming more and more frightened.
In the end, after an extra $6000 in billing and probably the worst
day of this mother’s and this child’s life, the end result could have
happened in the family doctor’s office. He could have listened to the
mother and the child and could have made a determination that these
thoughts were not connected to a plan or to an intent to die, but rather
an expression of how miserable the child felt. He could have written
the same prescription since this drug is widely detailed to family
doctors with instructions on its use. He could have given the mother
names of psychotherapists in the community to call. In an enlightened
office, he could have had a therapist on call for his office or visiting
on a regular basis each week to handle these kinds of situations.
Why didn’t he? One explanation is fear of malpractice. That drives
much of the insanity in American health care and is not so nearly a
problem in other countries. These other countries have social networks
to care for people who are injured in medical mishaps. We don’t. The
only choice available to our injured patients is to sue. Another
explanation is the silo model of American medicine. Each specialty
keeps to its own domain somewhat exclusively. Internists don’t talk to
psychiatrists and don’t treat psychiatric disorders. Similarly,
psychiatrists don’t talk to internists and don’t treat medical
disorders. However, the body is one. The arbitrary separations we
create do not actually exist in nature.
If we are going to actually afford an accessible health care system,
we will need to address these questions of how care is delivered.
Failure to do this will bankrupt our healthcare budget.