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CFHA: Heed the Prophet; Clinician: Corrupt Thyself

Posted By Randall Reitz, Thursday, June 30, 2011

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:

  1. "If care is clinically inappropriate it fails.
  2. If care is not operationalized properly, it also fails.
  3. If 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.

This same 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.

Wait, a 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.

However, in 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 amongst us.

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 the question.

So, there 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 companies.

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:

"CFHA 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”.

In 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.

Randall 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.

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Jennifer Hodgson says...
Posted Thursday, June 30, 2011
Well put Randall. Since its inception, CFHA has grown to attract other disciplines. Through this process the mission has stayed same. The central part of CFHA which makes it so strong is its diversity. I see its members as role models for true collaboration. CFHA is an incubator for professionals from diverse backgrounds, cultures, and disciplines who are learning how to work together and advance the art and science behind collaborative care. We are stronger together. CFHA is a place where it does not matter what part of the mission you embrace, but we recognize that collectively we enhance all parts of the healthcare system. CFHA promotes a shared belief in respecting the value and influence of all parts of healthcare and all professionals working within it.

Jennifer Hodgson, PhD, LMFT
CFHA President
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Randall Reitz says...
Posted Thursday, June 30, 2011
Interesting Jennifer, I see the connection between being multi-disciplinary and CFHA moving toward being less clinical in focus. The clinical knowledge and skills are the aspects of our members' careers that our most closely tied to our guilds, whereas the operational is the connective tissue between the guilds. As an MFT I don't need to know how to prescribe insulin, but I do need to know how to collaborate with a physician treating a patient with diabetes. Similarly, I don't need to know how to do psych testing, but I should be familiar with when and how to make a referral to a psychologist.
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