Like religions, academic fields are
led by both prophets and administrators. Collaborative care’s prophet is
undoubtedly CJ Peek.
His prophetic bona fides include his Yoda-like gravitas, his universal
devotion from our movement’s founders, his unmatched ability to distill arcane
doctrines into teachable articles of faith, and his usage of language that is
equally inspirational and apocalyptic.
While prophets generally only preach
one world-view, collaborative care is sufficiently pluralistic that our prophet
is best known for his three-world view:
care is clinically inappropriate it fails.
care is not operationalized properly, it also fails.
care does not make reasonable use of resources, the organization, its patients,
or society eventually go bankrupt and thousands of patient-clinician
relationships are disrupted” (Peek, 2008).
This dark prophecy is fulfilled daily
in collaborative care settings where the financial corrupts the operational and
the operational corrupts the clinical.
Allow me to explain myself. Just like
any church, the collaborative care pews are filled with fervent believers,
practicing adherents, and devilish apostates:
- Front-line clinicians are the true believers. We are the ones who have enough faith in
the cause to work outside of our areas of training for less money than could
be made for less effort elsewhere.
Had we practiced 2000 years ago it would have been said of us: "it
is harder for a clinician to leave a collaborative clinic as a rich man
than it is for a camel to walk through the eye of a needle” (Matthew 19:24).
- Operational administrators are the practical
adherents. They find that our model
makes sense even if the reimbursement pays only cents. However, they distract our daily
pilgrimage with banalities like efficiency and HIPAA compliance.
- Financers are the devilish apostates. I propose a corollary to the Peter Principle, which I’ll call the Judas
Judgment. It states that
"Clinicians keep the faith until they are advanced in their careers enough
to hold the money bag.” Then all they decree is "no
margin, no mission” as they cut collaborative care positions. It’s worse at the governmental and
healthcare payor levels where the virulent vestiges of carve-outs
eviscerate our sustainability.
corruption happens on a personal level.
Collaborative care is very demanding operationally. It’s not enough to have great clinical
acumen, we also need keen operational awareness. Before entering the primary care world, I
would regularly attend clinical conferences:
AAMFT, narrative therapy intensives, the Erik Erickson symposium. Since entering primary care, I have only been
to operational/financial conferences like CFHA.
I fear that if I weren’t teaching the behavioral sciences to family
medicine residents that my clinical skills and knowledge would have atrophied completely.
minute…did I just describe CFHA as an operational/financial conference? Now there’s a heresy. Well, look at last year’s Louisville conference: The plenaries were
political (Jonathan Cohn), corporate (Grundy/James) and operational
(Scherger). Similarly, of the 5
pre-conference workshops only the counselor and physician orientations could be
described as remotely clinical. All this
being true, I’m not convinced it’s proof of CFHA’s apostasy.
Just as I
have needed to focus more on the operational and eventually the financial as my
career has developed, our field has needed to follow the same developmental
path. CFHA’s archives reveal that our association was founded at a meeting of
family therapists and family physicians who attempted to answer the question
"No matter how financed, what should a thoroughly modern healthcare delivery
system look like at the clinical level?”
No matter how financed? Really? Now, there’s a mantra for a congregation
of true believers. While it served us
well as we coalesced our vision in safety-net and academic settings, this
myopia limited our growth to these same settings.
the larger healthcare system, it’s not only money that matters, there’s also
size and science.
Size matters—a movement based on the combined
efforts of family therapists and the family physicians who like to collaborate
with family therapists is bound to be a small movement. That being said, once the circle is expanded
to include other like-minded (though not doctrinally pure) groups, the model
invariably evolved. For example, just as
CFHA’s conference is not really about clinical skills anymore, it’s also not
really about family. In the heart of
this family therapist, this is a real loss.
Similarly, collaborative care has swung above its weight by aligning
itself with other movements—most notably the patient-centered medical home
(PCMH). While PCMH shares many of our
tenants, in its current formation the language is far too physician-centric to
appeal to the nurse practitioners and some of the more ardent behaviorists
Science matters—and will also corrupt our
model. The problem for true believers is
that faith and science have clashed for centuries. While collaborative care will never be
financially sustainable without a strong empirical case, when we engage in
honest science we surrender control of what the evidence reveals. For example, by my count 1st-tier
medical journals (JAMA, NEJM, BJM) have only published 2 or 3 articles on our model. However, while the authors of these articles
called what they studied "collaborative care”, a close reading reveals that
they are care management models that don’t make prominent usage of any sort of
behavioral therapist. While their
strong findings advance our cause beyond "no matter how financed” idealism, it
is markedly different than what the founders envisioned when they first asked
we have it, to survive in world of money and science we need to leave the
church and gain comfort in the world of publicans and sinners, and dare I say
Republicans and rich corporate winners.
But, in this challenge, I’ll cast my lot with the true believers. CFHA and collaborative care were built by
clinicians and we will be the ones to justify our movement’s place in the
healthcare mainstream. However, as
Brother CJ predicted, our clinical skills are insufficient in this
endeavor. As clinicians become leaders,
we need to corrupt our clinical purism with the realities of operations and
finances. In our role as leaders we’ll need to wield our motivational skills in
the unholy pursuits of lobbying politicians and negotiating with insurance
As we move
away from orthodoxy and orthopraxy, how will we know when we have completely
lost our way? I suggest that a reasonable test is to compare the models we
currently practice with the model described in CFHA’s mission statement:
promotes a comprehensive and cost-effective model of healthcare delivery that
integrates mind and body, individual and family, patients, providers and
communities. CFHA achieves this mission through education, training,
partnering, consultation, research and advocacy”.
comparison to the question at the heart of our founders’ vision statement, I
believe this is a mission trip that all of us true believers can continue to
take every day.
Reitz , PhD, LMFT is the executive director of CFHA and the behavioral
science faculty at St Mary’s
Family Medicine Residency in Grand Junction, CO. He and Ana Reitz have
3 children: Gabriela, Paolo, and Sofia.