PSYCHIATRICNEWS
by Mark Moran
October 29, 2015
This major milestone is in recognition of APA’s commitment to integrated care. The training that psychiatrists receive will enable them to expand their psychiatric expertise to larger populations of primary care patients.APA is one of just 39 health care organizations selected by the Centers for Medicare and Medicaid Services [CMS] to participate in the Transforming Clinical Practice Initiative, a grant program in which APA will receive $2.9 million over four years to train 3,500 psychiatrists in the clinical and leadership skills needed to support primary care practices that are implementing integrated behavioral health programs.
APA will train psychiatrists in collaboration with the AIMS [Advancing Innovative Mental Health Solutions] Center at the University of Washington and will offer both online learning modules and in-person training at APA meetings. Ultimately, it is expected that psychiatrists will be able to join ongoing learning communities designed to continuously share information and advice about how to implement the skills of integrated care into their practices and to transform clinical practice.
“We hope to leverage APA’s district branches to create local learning communities dedicated to changing clinical practice,” said Anna Ratzliff, M.D., Ph.D., associate director for education at the AIMS Center and director of the University of Washington Integrated Care Training Program.
The award is a milestone for APA, a high-profile recognition of APA’s commitment to integrated care and to the goals of its so-called “Triple Aim”: improving the individual experience of care, improving the health of populations, and reducing the per capita costs of care for populations. Of the 39 health care organizations, there are 29 health care networks, and just 10 “Support and Alignment Networks” [SAN], of which APA is one…
… the model:
[click image for description]
A patient in the real world.
She was in her early thirties, obviously "dressed up" to go to the doctor and clearly apprehensive about the visit. She lead with symptoms, "anxiety and depression" for the last several months. Her friend had noticed and suggested she come to the clinic and get on some medications. She was a stay-at-home mom with children 9 and 3. Her husband had a good job and their financial situation was stable. Her symptom list jibed with DSM-5 MDD. Exploration for some reason she might be depressed, something wrong in her life, was negative.
People aren’t stupid. If they know why they’re depressed, they’ll usually tell you. She didn’t, and was what Freud called "resistant" if I tried to pry. So, I backed up and took a parallel history.
She’d been married ten years. They were making it financially, owned their own house, and each had a car. Her kids were easy. Her husband was a "good provider," working as a plumber. He was from a city several hours away, a college town where they’d met. Like many in our rural area, he worked out of town, and was gone two or three nights a week. Most of his out of town work was in his home town. So when he was gone, he stayed at his mother’s.
Taking a parallel history, you follow anything that comes up that’s promising. Things are rarely this easy, but the first lead hit pay dirt.
When I asked what it was like for him to be gone that much, the apprehensiveness returned. It wasn’t too much longer before she said, "Lately, he leaves in his plumber’s clothes, but he’s been taking a change of good clothes with him. Why doesn’t he just take pajamas?" So I asked "What got you to worrying about that ‘several months ago’?" Without hesitation, she responded. "One night, I called to find out when he’d be home. He didn’t answer. I called over and over. Finally, he answered. He was on the road coming home. He said he must’ve turned off his phone by accident. He never does that"
From there, it was downhill. She’d lost interest in sex, and their relationship had become tense. I won’t belabor the point. This woman was worried her husband was "running around" on her with someone from his past and didn’t know what to do. Unconscious? Sort of, kind of. Maybe more like what Harry Stack Sullivan called selective inattention. But from her further story, her reasons for that worry seemed well founded. She and I had done our job, converting her symptoms into the real life worry she had been reticent to allow herself to fully face. Speaking of Freud, we had converted "neurotic misery" to "common unhappiness." I expect she’ll find the answer to that question she didn’t want to ask pretty quickly now it’s on the front burner.
Whenever I read about Collaborative Care, cases like this pour into my mind. This young woman was from a week ago, the last time I worked in the clinic. I feel kind of funny mentioning anecdotes and add some disguises to insure privacy. While it feels like bragging to present cases like this, I just don’t know how else to talk about what bothers me about Collaborative Care. When I look at that firewall between me and the patient in that diagram [twice removed], I feel defeated. It’s obviously put there to insure that I’ll stick only to medication management. And it’s a sure bet that’s what she’d be treated with if someone didn’t go poking around to find out what’s wrong. I don’t know how to poke through proxies – the care manager and the primary care physician. But I’m sure she isn’t likely to need any of my medication management expertise.
I think I’d be a lot more helpful in a consultant position to a primary care practice teaching them how to listen, how to take a parallel history, how to hone in on the emotional music that guides such explorations, how to ferret out unacknowledged conflicts, how to know that a perfectly reasonable person who has been depressed and anxious for a defined period hasn’t contracted some brain disease – something’s happened in her life. How to approach such things can be taught, and you don’t have to be a psychiatrist, psychologist, social worker, or a Freud wannabe to learn. It’s more in the range of careful common sense [AKA basic human empathy]. In lot of these everyday cases where medications don’t work, have been changed, are stacked on top of each other, the problem is like this – categorical – brain meds being given for life’s problems…
UPDATE: I guess I forgot to emphasize that I’m not thinking this version of Collaborative/Integrative Care is a very good idea. I’d prefer teaching all health care workers basic interviewing skills as a more productive intervention…
Lenin used to say capitalists would sell them the rope with which to hang them or something like that.
Psychiatrists in practice who support the APA (who supported mangled care and now collabo-care) in any way, shape or form fully deserve what is coming to them.
At this point, if you belong to that organization, you have forfeited your right to complain about how things are going.
Thanatos. Doctor, heal thyself.
Amen…
Back in the day when I taught medical students behavioral science, I told as many stories like this as I could sneak in between the facts they needed to pass their psych tests/boards. I still run into those students and I’m proud to report that they always bring up the stories, recalling the cases even thirty years later – sometimes giving examples of their own. Somehow, “case reports” have gone out of favor, but they were on the top rung for me – both learning and teaching. It’s sort of like a picture’s worth a thousand words.
As for the APA, my impression is that they’re going along with almost any and everything as penance for some really misguided behavior over the [too many] years – trying to barter for a place at the table rather than championing the cause of our patients or even their own members. If we want to do something for primary care, maybe we should “unteach” the massive over-reliance on prescription pads that grew out of control during the last twenty “pharma-crazed” years, and redefine when “to medicate and not to medicate“…
If the moral masochism theory is correct, the KOLs are making the dues paying suckers in private practice pay the price. I would suggest forfeiture of tenure and honoraria would be a purer form of cleansing one’s soul. I won’t hold my breath.
I think it really comes down to the fact that those in charge are true believers in ACA and will do anything to make it happen including the promotion of doctors not seeing patients. In other words, ideology trumps professionalism.
I think the point is that business managers have successfully infiltrated and taken over the practice of medicine. The power game involves marginalizing physicians and there is no better way to do it than suggest that a checklist is better than a comprehensive evaluation, that there is nothing “medical” anymore only health preserving activities courtesy of corporate America like the EHR rather than EMR, and that you only need a prescriber and not an extensively trained physician.
The AMA and APA excursions into collaborative care is another example of just how naive physician professional organizations are. They have no clue when they are being outgamed by business and financial types.
That is an important distinction because it is just plain ignorance of politics or an unwillingness to engage in that process. Physicians are actually well known avoiders of politics and confrontation. They even want to avoid talking with those of us who are not.
Frankly, check out the November issue of Psych Times, front page, “Fraud, Waste, and Excess Profits” by Torrey. Some of it is just pontificating, but, on page 24 in bold is this quote:
“Perhaps the largest amount if state controlled mental health funds, however, is being lost through excess profits taken by for-profit managed care companies.”
No surprise, right? But, the point of this comment is the APA has historically supported things that benefit the few, ie, them, and don’t give a rat’s ass about the majority of providers or patients. They support this crap above, they support the faux Mental Health care atrocity bill by that charlatan from Pennsylvania, and they supported the CBT crap that has helped decimate private practice, at least those who are honest and responsible.
Oh, and they supported Managed Care once they realized who had the money. Hippocratic Oath, nah, we see a bunch of Hypocritical Oafs at the APA!
Gee, kinda mirrors what politicians have been doing for the past few decades, and for me at least, what the fraud in the White House has been doing to the rest of the country as well.
For what it is worth, George Carlin had the best quote that resonates in those who are attentive and accountable: “when you have selfish ignorant citizens, you get selfish ignorant leaders”, and thus, when you have selfish ignorant psychiatrists, you will have an organization like the APA filled not only with selfish ignorant leaders, but, again in my opinion, alleged professionals who have no souls that deserve the title of physician, at the end of the day.
Oh, I forgot to mention, they at Psych times included a commentary by Allen Frances to the Torrey article, he ends with this: “Change will com eonly when our collective shame overcomes our current inertia”.
Cue the video of coach Jim Mora when asked about going to the playoffs years ago after a pathetic loss by his football team:
“Shame? SHAME?! Who the hell is talking about shame, with this group?!?!”
Note my name now is not tied to my blog, that has expired.
I don’t think the leaders of the APA are naive. None of this will affect them as they are running around in a different Skinner box. I think they are either hostile to or don’t care about private practice. It doesn’t matter which is the motive, the result is the same. That the rank and file keep electing people hostile to their interests is the death wish. By people who are supposed to understand human behavior.
Not sure what the training program entails but 2.9 million to train 3500 psychiatrists works out to be about $825 per psychiatrist to do all of this training. I doubt much in the way of leadership and clinical skills will be taught.
Another Amen…
Collaborative Care is the Emperor’s New Clothes. But only the people with no power are willing to acknowledge the Emperor’s butt waving in the breeze.
When I look at this model I think of Chicago’s notorious Dr. Michael Reinstein and the 4,000 “patients” under his “care.” Most of them poor folks with serious mental health problems, crammed into fleabag nursing homes. Their only real human contact was likely with a “case manager” in the form of some over-stressed social worker or LPN who reported to one of the second-rate primary care doctors that regularly “practiced” at the home.
They would then tell Reinstein what they needed to keep the patient manageable, and he’d come in to sign off on it, a couple hundred patient charts at a time. The meds he prescribed would depend on whatever drug company he was playing house with at the time. Usually Seroquel or clozapine. When he did show up, the nursing home would need a security guard to protect him from the dozens of patients trying to get to him and beg for a respite.
Take out the frank bribery by AstraZeneca and Teva, and the model pictured above becomes the Reinstein Model, pure and simple. One thing that sticks out like a sore thumb: there is no arrow between the psychiatrist and the patient. There’s not even an arrow between the psychiatrist and the patient’s doctor. So, the psychiatrist is a “doctor” without any patients. Without a referring doctor either, really. Nice!
Superficially it looks like the Case Manager is the most influential person in the setup. However she (and it will usually be a she) will be so completely at the mercy of a “care” model designed by the psychiatrist and the insurance company–the two parties that never lay eyes on the patient — that her power will be next to nothing. She will end up being more the “beat cop” for the parties who make the rules than the “therapist.”
So a model once considered scandalous will be officially blessed as a “Best Practice”! I wonder, as Reinstein heads off to do his little 18 months in the pen or whatever trifling sentence he gets, will he feel resentful, or vindicated? This is truly sick.
Johanna,
The biggest Amen of all,
And by the way, that RxISK blog about FDA nominee Dr. Califf was a twelve on a scale of one to ten. Super sleuthing extraordinaire!…
“”The power game involves marginalizing physicians and there is no better way to do it than suggest that a checklist is better than a comprehensive evaluation””
Great point Dr. Dawson as that is what I feel going to my PCP has turned into. By the way, I think she is a good doctor but is forced by the organization she works for to essentially engage in what I call check list medicine.
For example, all patients are asked to fill out this functional assessment questionnaire before their appointments that smacks of psychiatric integrative care big time. I have tried to find out more about this questionnaire and the reasoning behind it but I finally gave up and will simply refuse to fill it out which is my right.
Sheesh, there is barely time to cover the issues that one goes to see the doctor for and they want you to fill out this out? Give me a break.
Sorry Mickey, one more comment. I think of all the people on the apnea boards who were misdiagnosed with psych disorders when they turned out to have sleep apnea. Psychiatric integrative care will make that alot worse in my opinion as now, all the sleep complaints that may be due to sleep apnea will be referred to an integrated care psychiatrist who will most likely prescribe medication without investigating further.
“… without investigating further.” I take your point but would add that with the model in that diagram, they couldn’t be able to see the clinical clues or, for that matter, ever “investigating further” even if they wanted to. They’ll never see the patient in the first place.
Psychiatry was far from perfect when the analysts ruled, but I can say with certainty they would never let something like this happen. In fact, you would probably get thrown out of the room for even suggesting patient care without patient contact.
In fifty years the patient relationship has gone from the central focus of treatment of the individual to the perceived obstacle of treatment of populations.
As far as psychiatrists go, in my opinion, if you believe the increased marginalization of your role will help you or your patients, then you may not in fact really understand human behavior or recent history that well. This isn’t difficult. Look at the what has happened to optometry in the past forty years and what is happening to diagnostic radiology now.
You’re so right Mickey and that is what makes the situation even worse.