Fairmount Primary Care Center (FPCC) is not a big place. There’s a hallway for adult medicine with ten exam rooms, two apiece for each of five providers. There’s a hallway for pediatrics with four exam rooms for the two pediatricians. There are various support and administrative spaces—a waiting room, a front desk, an alcove full of medical records, a couple of triage rooms, a lab, a nurse’s station, a room full of computers where the providers sit to chart, storage closets for supplies and medications. And there is a behavioral health office, which until recently was a modestly-sized windowless room tucked in beside a back stairwell, next to the copy machine and a corridor leading to a bathroom that was usually out of order.
The behavioral health office was occupied by the director of behavioral health (my supervisor, Suzanne) and shared with the two behavioral health interns (me and my colleague Frank). It was furnished with a couple of computer work stations, a few chairs and a bookcase. We used it for consultations with patients who had been handed off to behavioral health by their providers, for scheduled followups with patients and family members, for charting and making phone calls, and for supervision. With all three of us using the room for all these purposes, it got a little crazy sometimes, like when more than one of us had a patient to see at the same time. Mostly, though, it was adequate.
Then the social worker quit. She was the latest in a string of social workers to quit after not very long on the job, and it fell to Suzanne to try and figure out why. Part of the problem, it appeared, was the location of the social worker’s office, which opened directly onto the waiting room and made the social worker vulnerable to limitless demands by both patients and staff. Suzanne hired a new social worker, and moved the new hire into the only other space available—the behavioral health office. It was a vast improvement for the social worker, who now had enough control over her time and space that it was possible for her to do her job.
It was not an improvement for behavioral health. Behavioral health couldn’t just move into the former social work office, since that office’s semi-public location would have made it impossible to safeguard patient privacy. But the office now shared between behavioral health and social work was now occupied by a rotating cast of patients consulting with the social worker. Suzanne and Frank and I couldn’t meet with patients there. We couldn’t make phone calls. We couldn’t talk with each other. We couldn’t even find places to put our coats. Right about the time this change happened, a consulting psychiatrist began coming to FPCC one morning a week. She, too, was supposed to work out of the behavioral health office. Guess how well that worked?
|The space crunch highlighted a question that had been percolating along in the back of my mind for months: what exactly is the place of integrated behavioral health? Even at FPCC it’s not really clear how integral a part of the operation behavioral health is. Suzanne has been there for 17 years, and patients still occasionally report that when they return for followup visits with behavioral health, the front desk tells them that there is no such department. It strikes me that this may be less a problem with the front desk personnel than a realistic reflection of the medical care system as a whole. Everybody knows that medical offices are staffed with doctors and nurses. But behavioral health? What’s that?||"As much as I want there to be room for integrated behavioral health...it’s not clear how or whether that’s going to happen in any significant way."|
On the mental health side of things, I don’t see much more evidence that integrated behavioral health is any closer to achieving mainstream status. It’s certainly not represented in the curricula of the majority of training programs in my field, marriage and family therapy. In the large and thriving master’s program in which I am enrolled, I have yet to hear the subjects of physical health and illness even mentioned, let alone explored. I got my internship at FPCC approved only with difficulty, and I have the sense that my faculty supervisors are less than enthusiastic about the work I’m doing there. After all, it’s not specialty mental health. And they’re right—it’s not. It’s primary care.
As much as I want there to be room for integrated behavioral health, both in the worlds of biomedicine and of mental health care, it’s not clear how or whether that’s going to happen in any significant way. It really seems like such a shame. Biomedicine is a fine thing, and so is specialty mental health care. But there is never going to be enough individual or family therapy to go around, and it’s more than lots of people need or want anyway. And part of the reason the medical care system is bankrupting us all is that we keep throwing more pills and procedures at problems that have at least as much to do with intrapersonal and interpersonal dynamics as they do with physical health or illness.
Just the other day I saw a patient for an integrated care visit. "What brings you in today?” I asked, as a prelude to my standard set of screening questions. She had pain in her shoulder, she said, radiating up her neck and down her arm and side; it had been this way for a couple of months. "What was happening a couple of months ago?” I asked. The patient couldn’t think of anything, but as we talked, more of the particulars of her life emerged: she was the single mother of two young children, going to school, negotiating details of child care with her mother, who was herself rearing two grandchildren close in age to the patient’s children.
It struck me that this patient’s pain might have a lot more to do with her mother than it did with her shoulder. "You know,” I said to the patient, "we don’t do ongoing therapy here, but we would be happy to meet with you on one or several occasions to discuss this further. You could bring your mother, if you liked, and we could all talk together.” "Really?” she said. "What would I say to my mother, to explain why I was bringing her in?” Later in the day I looked at the patient’s chart. The provider had found no organic basis for her pain, but noted that the patient had said she would like to follow up with behavioral health.
In ensuing days I found myself puzzling over that pain in the patient’s shoulder. If the pain was about her mother, why was it in her shoulder? A pain in the neck I could understand, but why a pain in the shoulder? An image came to mind of the patient and her mother, yoked together, rearing children of the same age, but being themselves of different generations, and one of them the parent of the other. No wonder they were having trouble pulling together. Behavioral health and biomedicine are having trouble pulling together, too. In the current culture of medicine, biomedicine is the established player and behavioral health the young upstart, and it is hard to learn to work together.
Will my patient come for a follow-up visit? Maybe she will. Maybe she’ll even bring her mother.If she does, we have a place to meet. After Suzanne and Frank and I and the social worker and the psychiatrist had spent a week falling all over each other in the behavioral-health-cum-social-work office, Suzanne said, "We have to do something about this!” The following week a corner of the office was partitioned off into a consult room. The office wasn’t big to begin with, and the new consult room is the size of a closet, and not a very roomy closet at that. But it has a door and a couple of chairs, and it’s definitely better than nothing. And in a sign that perhaps things are looking up, the bathroom down the corridor is even working.