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Collaborative Follies 1

Posted By Susan McDaniel and Andrew Pomerantz, Thursday, April 5, 2012

Susan McDaniel


Susan McDaniel PhD, Family Psychologist

University of Rochester

One of my first medical referrals was from an obstetrician on faculty in Family Medicine . He requested a "psychological evaluation" of a thirty-nine-year old single female patient who presented for donor insemination to have her first child. The obstetrician said he always asked any single OB patients to see a therapist, both for his own protection and for the patient and her family to have the opportunity to discuss the request and its likely consequences.

I thought this a fairly simple, straightforward request and scheduled a session with the patient, her mother, and her sister to discuss the procedure. I asked to see the patient only for the first half of the session. It quickly became clear that she was quite ambivalent about the procedure and more interested in proving to her family that she was an "adult” than she was in actually raising a child. In the second half of the session, the woman told her mother and sister that she did not want to proceed with the insemination and the family ended by agreeing to open more communication and contact among themselves. It seemed a good use of 50 minutes. However, when I reported this outcome back to the referring physician, he became angry, saying I "talked this woman out of her last chance to have a baby."

Like a bolt from the blue, I realized that I had not explored this physician's view of the problem when he made the referral. It was several years before I saw another patient of his. One of those lessons I had to learn again: to spend time early soliciting the physician's view and discussing the possible outcomes of a consultation.



Andrew Pomerantz


Andrew Pomerantz MD, Psychiatrist

Veterans Health Administration

My second attempt at integrated care took place at the White River Junction VA medical center in Vermont in 1989 (the first was in 1974 when I was still a Primary Care physician in the community). A psychologist and I opened an office in the primary care clinic and told everyone we were there to bring mental health care to primary care so we could reduce stigma. For a month or so, we sat there one afternoon every week reading journals (and probably some magazines as well).

Finally a patient with PTSD and alcohol dependence was deposited on our doorstep. We double-teamed him weekly for a month, after which time he asked us why he couldn’t just go see us in the mental health clinic where it was quieter. We said it was because we were trying out a new way to provide care. A month later he moved to Montana. By that time primary care needed the space back and we folded our tent and moved back upstairs. I did hear from him a few years later when he returned to Vermont with end stage lung cancer. We had a few visits – in the mental health clinic.

It’s often said that a plan without action is a daydream and an action without a plan is a nightmare. In this case, all I knew what that I wanted to provide mental health services in primary care, so I put out my shingle and waited for them to come. I had no plan, just a dream that ran afoul of the details. Though it did not turn out to be a nightmare, it taught lesson one: Integrated care is not just about co-location. It is a different paradigm. It also requires education of the customers (in the commercial world, that’s called marketing). In this case the main customers were the primary care staff.

Over the next 15 years, I tried many different approaches, each building on the experiences of the previous one. Finally, a concerted planning effort that involved primary care leadership and all of our mental health clinicians fulfilled the dream and the program unveiled in 2004 soon became the gold standard for co-located collaborative care in the Veterans Health Administration and, more recently, a core component of the Patient Aligned Care Team, the VA version of the Patient Centered Medical Home. 

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