1 Boring Old Man

Don’t think it is that big of a move. The APA has been positioning itself to basically do 2 things in order to stay viable:

1. Produce a guidebook for the ICD codes also known as the DSM..
2. Provide manpower to the managed care industry and whatever research will be allowed under the cooperation of the government with the managed care cartel.

It is really as simple as that. And who knows they may be selling it to the latest graduates if that is all they have seen?

I hope that Sandra Steingard has it right, that the mental health part of integrated care would be handled by counselors and therapists. (She thinks psychiatry would be subsumed into neurology, which would serve the “diseased neural circuits” branch of psychiatry right — but I suspect psychiatry will resist this for quite a while.)

But I fear, rather, that what medical care integrated with psychiatry really means is that medical conditions will be treated preemptively and routinely with psychiatric drugs, interpreting the emotional distress that may accompany illness as a psychiatric disorder, see http://medicalxpress.com/news/2013-02-ptsd-symptoms-common-icu-survivors.html

“But I fear, rather, that what medical care integrated with psychiatry really means is that medical conditions will be treated preemptively and routinely with psychiatric drugs, interpreting the emotional distress that may accompany illness as a psychiatric disorder,”

I guess you missed it. Managed care has been doping this for decades as the vast majority of this has nothing to do with psychiatry. I would estimate that over 80% of those prescriptions are written by non-psychiatrists. The idea that there will be an influx of counselors and therapists is a pipe dream.

Why pay counselors when you can now prescribe an antidepressant for $48/year?

It is always interesting that the psychiatry bogeyman is marched out as something to fear in integrated care when in fact – managed care is the problem here and not psychiatry.

No, I haven’t missed that. You may note the article for which I provided a link comes out of psychiatry.

My fear is that having a psychiatrist on the “team” is not going to reduce overprescription of psychiatric drugs — rather, the opposite, as psychiatric drugs are routinely added into a drug cocktail for “medical” purposes.

This may be of interest:

http://www.kevinmd.com/blog/2014/04/work-fringe.html

Steve Lucas

Has anyone actually looked at what this does to medi-mal premiums? I’d like to see this quantified.

1. Taking on responsibility for many more patients.
2. Less direct contact with patients.
3. Increasing number of patients likely to sue (Medicaid lawsuit rates are much higher, for example).

I’ve heard the average psychiatrist has a suicide in his practice every four or five years. Get ready for it to be an annual event.

You take on hundreds of patients, you don’t see there will be mistakes, and even if its not on you, you will be named.

Not a field I can recommend to any young person at this point.

“Has anyone actually looked at what this does to medi-mal premiums?”

Let’s implement it and find out.

A Primer on Integrated Care: FAQs Answered by Experts only briefly touches on the subject of liability, yet I had to include the link here if only for the last FAQ. It ends with:

“Many psychiatrists report these experiences as not only professionally rewarding but also “fun.” If we can show medical students and residents how exciting this work can be, then maybe we can recruit more to join us in this effort.”

I found this exert from the link that Arby provided:

“”Given the numerous barriers to obtaining primary care, and the continued early mortality despite our efforts, there is a growing movement for psychiatrists to treat some common medical problems such as dyslipidemias, hypertension, and diabetes.””

Let me see if I understand this correctly. Psychiatrists are going start treating medical problems that many primary care doctors have difficulty treating caused by medications they are prescribing? And how do they propose to do this? More meds so the typical patient will now be on about 9 drugs for everything. Yeah, that will work.

And yes, if anyone wants to know, I am being sarcastic big time.

This is an evasion:

What about liability for informal consultation?
The issue of liability in integrated settings can be considered along two lines. The first is whether a doctor-patient relationship is established. Legally, this is usually determined by whether there is direct evaluation of a patient (in person or by televideo) and subsequent documentation of findings. Indirect or “curbside” consultations do not establish a doctor-patient relationship, so involve minimal liability. An additional area of consultation in collaborative settings in primary care is between the consulting psychiatrist and the behavioral health provider. Liability in this situation can depend on the role of the psychiatrist, which can range from consultative to collaborative to supervisory. Liability is increased if you are the supervisor of the behavioral health provider and are ultimately responsible for the care provided.
The primary care provider retains overall responsibility for the patient and may choose to use the consultant psychiatrist’s advice or not. The PCPs also write all orders based on the consultations — not the psychiatrist, who is just in the consultation role.
—Lori Raney, M.D.

Two more thoughts on this:

If Dr. Raney is correct, then there’s no reason to have medi-mal at all with this model. Yet who is willing to make that move?

If Dr. Raney is correct, this is a huge disincentive to see the patient, even when it might be indicated.

She used the term “minimal” instead of “no” when referring to liability.

This does touch on another issue. Today many specialists are taking on the role of primary medical provider for their patients. PCP’s are passing this responsibility along as patients are referred to specialists who then take control of all of a patient’s medical needs.

Instead of the shot gun approach many patients find in a PCP’s office patients find a focus on a problem with a concrete plan focusing on a solution with a specialist. The financial incentives for 90 day visits and more and more medication does not always lend itself to finding solutions.

Specialists often spend more than the typical 12 or fewer minutes with a patient and tend to look for medical relationships instead of isolated problems. High BP may be due to a marriage dissolving and counseling may be a better prescription than a medication.

This expanded role may be something a psychiatrist does not want, but may be part of their practice out of necessity.

Steve Lucas

Just wanted to say goodbye, since I am at a hotel site that can’t be traced by my usual name and email sites, so hope Dr Nardo can find the time to tell readers why he has banned me.

Joel Hassman, MD

Joel,

I haven’t. I’ll check and see what happened.
…
Sorry. They were turned into spam on 04/25/2014 for unknown reasons. They weren’t even sent to my email. Please make a comment and let’s see if It’s fixed. I marked the ones it called spam “not spam.” My apologies…

Testing testing 1 2 3…

Sorry to assume i was banned, but the circumstances of how it happened were similar to past banning at a mental health site a few years ago, so thought “here we go again”.

My condolescences to your recent losses, hope you are moving forward as able. So, are you going to the APA?

Giving up direct patient contact and limiting involvement to a consulting role almost sounds like the concession of someone who is sick of seeing patients. APA is selling this as some kind of shelter in the storm. But there are bears in that cave. Ask the diagnostic radiologists who were replaced by far cheaper consultants overseas.

I think the last thing you want to give up in the age of Skpe is direct contact. Not to mention the hazards of trusting someone else’s mental status exam.