“I’d like to talk to you about this patient….”
Some presidents follow a format for these columns. I have nothing against formats except that I hate them for their…well, “formatness.” The way I see it, I get to write to you all about 10 times this year and they’ll print what I write pretty much for free and without question, as long as I make some degree of sense and don’t embarrass myself or the profession too much. So, what I’m really trying to say here is, I hope you enjoy what I have to say. I hope it makes you think a little, and more importantly, I hope it makes you want to talk to another psychiatrist a little, because that’s my goal as your president – to get you involved in the conversation.
I just got back from Russia. I spend about a week or two a year teaching AIDS Psychiatry in various cities in Russia. Nowhere glamorous. Usually, I get to go deep into Siberia in the middle of winter and freeze off body parts. Although, there is something to be said for opening a conversation with “The last time I was in a Siberian prison….”
AIDS Psychiatry is an interesting little niche. Basically, I see patients with HIV infection who have mental health problems. For the most part, people think that the role of the psychiatrist in this area is mostly dealing with grief or other adjustment issues – basically talking to folks about their concerns over having a life-threatening infection. Slightly more sophisticated, some recognize that the action of HIV in the brain causes mental problems – dementia and major depression are examples. But what many don’t think about is that HIV infection is an outcome of mental illness. That the reason we have such a high concentration of individuals with mental illnesses in HIV clinics is that their mental illnesses render them vulnerable to behaviors that lead to outcomes like HIV, hepatitis, imprisonment, homelessness and other disenfranchisements. And once they’re infected with HIV, we have complex mentally ill patients that now have to try to manage a life threatening infection along with their mental illnesses. Basically, that’s my job: help the most vulnerable manage an incredibly difficult task, for the rest of their lives.
Now I’m not telling you this to toot my own horn. I’m telling you because I learned, from a whole lot of firsthand experience, that all this integrated healthcare, medical home, accountable care mumbo-jumbo really works.
In my clinic, the psychiatrists work in rooms next to the medical doctors. Today in clinic, I spoke to Mark Sulkowski, infectious diseases doc specializing in HIV-hepatitis C coinfection. We have several patients together. I know I can knock on his door anytime he’s not with a patient to discuss a patient or the latest new drug for hepatitis C (we have two new protease inhibitors that will likely increase cure rates). We also have social workers and pharmacists and case managers and primary care docs and OB/GYNs and dermatologists and ophthalmologists and neurologists. And we all write in the same charts and manage the same patients together.
In Russia, no such system exists. Last week, we were discussing the tricky problem of managing patients with HIV infection, active tuberculosis, and active injection drug use. The biggest problem is there is no system. TB is treated in the TB clinic, HIV in the HIV clinic, and drugs in the “narcology” clinic (which is independent of both psychiatry and general medicine). And nobody talks to anybody else. The Russians are fascinated by the stories of how my clinic, and other HIV clinics in the US with some of the same services, manage complex patient issues. They are in awe of the resources we can bring to bear to overcome a problem like adherence to medications. And they are also in awe of our commitment to the public health that permits us to take a stand like mandatory TB treatment using directly observed therapy.
At the MPS annual meeting, I made a short speech. I said I wasn’t going to stand up to say we have a broken health care system because I didn’t believe it, and I still don’t. I think we have great health care in the US – it’s just not universally very focused. We’ve let freedom to choose (a really good thing) gum up a system that can, and sometimes does, work wonders.
And our profession has taken that a step farther. We’ve lost ourselves a little in psychiatry and forgotten what makes us most useful to our medical family – our ability to influence attitudes and behavior. We’ve occasionally let our patients excuse behaviors with mental symptoms and allowed them to fail because we sometimes overvalue their free will to choose to ruin themselves.
We face issues in the approaching health care “reform.” The same kinds of issues Russia is facing. Do we remain in silos and let patients fail because they don’t integrate for us, or do we step into each other’s spaces and learn to co-manage difficult cases? Do we let payors divide us and limit our work together, or do we strive to demonstrate how effectiveness in one compartment can have benefits in another, thus balancing out for the “whole patient?” Do we become so specialized in our area that others with no medical training threaten to replace us because they are willing to work cheaper, or do we demonstrate the enhancement medical training has on our ability to integrate with our medical colleagues?
Every time we pick up the phone to talk to the patient’s primary care physician, we integrate health care a little more. Every time we fax over a note, or send a short (encrypted) email, we integrate a little more. Shared access to an electronic medical record between Emergency Department doc and psychiatrist? You bet that’s integration. And you’re already doing it all the time, I know. So this “reform” should be a breeze, right? I guess that’s why I can spend some of my time working on the Russian problem.