Dr. Pomerantz's post is the second in a 3-part series leading up to the 2014 CFHA Debate at the Conference in Washington DC. The debate will present major issues that have yet to be clearly resolved in the professional literature.
Let’s assume that you managed to find the end of the rainbow and found that elusive pot of gold. Being the good PCMH (Patient Centered Medical Home) fanatic that you are, you decide to spend it all on integrating mental health services into your medical home. Alas, you find the price of gold has dropped and all you have is enough to hire one full time therapist, one and a half nurse care managers OR one measly day per week of a psychiatrist. No one in his or her right mind would choose the latter of those three but I am here to argue on behalf of it anyway; for two reasons:
Reason 1: Past is prologue to the present
First, see Dr. Simmons’s recent blog entry arguing that the leader of the PCMH should be a physician. I won’t repeat the points he made about the depth and breadth of training of family physicians, other than to say that psychiatrists have similar training, encompassing psychological, social, biological and spiritual aspects of human health and well-being (OK, I hear you and will withdraw the claim for the generalization about spiritual – I am one of the lucky ones who has worked intensively with clergy for decades).
From the earliest days of healthcare (shamans, etc), organized societies have identified specific individuals as healers, whether by divine choice or by schooling and training. At times they were treated as slaves to the masses but, thankfully, long before I came around, we were getting a much better deal. Like it or not, our culture still carries the belief that we physicians are the only ones with the depth of knowledge to help them attain or maintain health. The buck stops with us. Do I like that? Not particularly. I’d much rather share the burden but, when it comes to societal norms, third party reimbursement or medicolegal liability, we are “it.”
|Without a psychiatrist, patient outcomes are at risk |
Randomized clinical trials (such as IMPACT and RESPECT) using nurse care managers have clearly demonstrated their value in achieving the triple aim. Patient outcomes are improved, patients like the care and costs are reduced. But care management protocols require a supervising (not consulting) psychiatrist to review cases, make recommendations, do some troubleshooting and identify patients who need more than telephone care. Without a psychiatrist in the mix, costs are still reduced and patients might be happy but outcomes are at risk. Better to have a psychiatrist working in the PCMH and have him or her train primary care nurses to run the protocols. PC nurses often do much better than mental health nurses because they don’t digress into therapy but stick to the protocols.
As for therapists, first let me say that my closest professional colleagues are therapists. Some of my friends as well, though I prefer being around people who don’t do anything like what I do. They are great but usually lack the biological understanding of the mitochondria gone wrong or the demyelination progressing or any one of a number of physiological perturbations that often masquerade as troubles needing therapy. As a consultation psychiatrist I’ve seen too many patients getting treated for panic disorder while their thyroid goes unchecked or patients with early multiple sclerosis being treated for conversion reactions. Behavioral presentations of serious illnesses or drug interactions often get in the way of the PCP evaluation and it’s up to the psychiatrist to sort it all out. Someone has to be looking at the cases before jumping into therapy.
Reason 2: Odysseus
No, not Oedipus. Odysseus, husband of Penelope, son of Laertes and Anticlea and so on. Odysseus faked mental illness in a futile attempt to avoid winding up in what became the Trojan War. Once in the war, he is credited with coming up with the idea of the Trojan Horse. The Greeks presented this hollow wooden horse filled with soldiers and led by a front man to the Trojans and the rest is history (truth be told I have a tough time distinguishing myth from history but after a certain period of time it doesn’t matter). “Beware of Greeks bearing gifts” is a common phrase even today.
Why the digression? Let’s say everyone follows my recommendation in this blog. When all that we are doing to improve healthcare becomes ancient history that one-day-a-week psychiatrist will be known as our front person for a horseload of psychologists, social workers, peers, nurses and others. The psychiatrist, while often maligned by some medical colleagues, is still “one of us” when viewed by the PCP. The MD after the name immediately generates a trust that PHDs, RNs, LPNs, MSWs and others often spend years trying to establish. Get me in the door and after I say for the hundredth time “need someone else to help get that A1C down and get the pain under control,” they’ll be begging for the rest of the team.
Dr. Pomerantz is the National Mental Health Integrated Care director for the Veterans Health Administration and Associate Professor at the Geisel School of Medicine at Dartmouth (which he prefers to think of as the Dr. Seuss School of Medicine). He spent the first 12 years of his career as a PCP carrying his little black bag around the hills of central Vermont before training in psychiatry in hopes that it would make him a better PCP. Unfortunately, he never went back, though he works virtually from an office just down the street from his former practice. If he ever gets broadband at home, he’ll work from where he belongs. He still has his little black bag, just in case.