The Most Important Role for Psychiatry in Integrated Care

PSYCHIATRIC VIEWS ON THE NEWS

I suppose that I could just refer you to the essay in the November, 2014 issue of The Atlantic and stop. Written by Meghan O’Rourke,¹ the article has a lengthy title and subtitle: “DOCTORS TELL ALL And It’s Far Worse Than You Think-A crop of books by disillusioned physicians reveals a corrosive doctor-patient relationship at the heart of our health-care crisis.” End of this blog.

You can stop reading now-but I think what it tells us, and what I sensed near the end of my own clinical career, as well as my own experiences as a patient, the topic is so important that it seems worth reviewing in more detail. The accumulating news about our medical systems is not good. Our own personal wellness, the health of all health caregivers, and the well-being of patients, may depend on the response to this crisis.

[[{"type":"media","view_mode":"media_crop","fid":"28753","attributes":{"alt":"Integrative Medicine","class":"media-image","id":"media_crop_729526143363","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2935","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":" ","typeof":"foaf:Image"}}]]We in mental health care may be the last bastion of defense in this deterioration of the doctor-patient relationship. However, this potential role seems to be underplayed in the call for more integrated medicine of psychiatry with general medicine.

Of course, the essay and multiple books by physicians that are summarized in the article may be sensationalized to some extent, but here are some of the points that got my attention and had me nodding in agreement. Some may be obvious and well-known. Others perhaps not so.

• “For a system that invokes ‘patient-centered care’ as a mantra, modern medicine is startlingly inattentive-at times actively indifferent-to patients’ needs.”

• “Doctors today are more likely to kill themselves than are members of any professional group.”

• “The alarming part is how fast doctor empathy wanes.”

• “Yet empathy is anything but a frill: not only is it crucial for doctors’ humanity and patients’ dignity, it can be key to medical efficacy.”

• “And so each side exercises power passively (or passive-aggressively), and maybe even unconsciously.”

• “Currently, we must seek it (care, that is) in a system that excels at stripping our medical shepherds of their humanity, leaving them shells of the doctors (and people) they want to be, and us in the sterile rooms they manage.”¹

The other side of this clinical coin is presented by the authors of a new Perspective piece published October 23rd in the renowned research journal, New England Journal of Medicine: “Public Trust in Physicians-U.S. Medicine in International Perspective.”² It indicates that the public trust in US medicine is much lower than in many other countries. One side of the coin is the patient mistrust of the system. On the other side is physician mistrust of the system. Too many times they meet in the tarnished metal of mistrust.

Perhaps because she does not work in medicine, Ms O’Rourke poses no real solutions. Sure, we do well in medical crises, just as we are coming to do in the Ebola outbreak. It is everyday medicine that is the real challenge. She does praise another kind of slow movement, “slow medicine,” meaning more time with patients, but poses no way to get there. She does mention that Canadian caregivers have much more time with patients. So continuing to push for a Canadian-style single payer system is implied. However, given that we are still rolling out the much different Affordable Care Act (ACA), that will not happen any time soon.

The good news is that the ACA lays out incentives for more integration of mental health care clinicians into general medicine and vice versa. The reasons, while laudatory, don’t get at this crucial problem for doctors. Recommendations are generally for psychiatry to be more available for patient consults with other doctors; for being on-site sometimes to occasionally see patients as needed; and for general medicine to better attend to the often neglected medical needs of the mentally ill.

All of that is well and good, and recommended for decades, but it doesn’t at all get at the problem that this essay and the books reviewed presents.¹ Doctors are finding it harder and harder to be the healers we want to be beyond the technicians we are limited to being.

As we wait and fight for a better health care system, it is the well-being of physicians, nurses, and other clinicians that need the most attention. Their disillusionment needs empathy and emotional support in order to help prevent burnout and worse. Who knows passive-aggressive behavior and the unconscious, which the author of the article mentions is commonplace, better than us?

How to do that in our limited time is quite the challenge. Perhaps ventilation meetings to blow off steam together instead of at patients. Perhaps literature distributed to better understand the problem. Perhaps educating the public to get them more on our side. We need to use any opportunity and idea we can to help maintain the morale and morals of medicine.

References:

1. O’Rourke M. Doctors Tell All-and It’s Bad. The Atlantic. October 14, 2014. version: http://www.theatlantic.com/magazine/archive/2014/11/doctors-tell-all-and-its-bad/380785/. Accessed October 23, 2014.
2. Blendon RJ, Benson JM, Hero JO. Public Trust in Physicians-U.S. Medicine in International Perspective. N Engl J Med. 2014; 371:1570-1572. http://www.nejm.org/doi/full/10.1056/NEJMp1407373. Accessed October 23, 2014.