“Who’s Gonna Mow Your Grass?”

Jim pretending to mow the lawnSo I finally heard about Chris Cox, alias the Lawnmower Man who came all the way from South Carolina to Washington, D.C. during the Federal government shutdown to mow the lawn and pick up trash around the Lincoln Memorial since no one else was going to do it.

CNN’s Don Lemon interviewed him and my favorite quote from the Lawnmower Man was, “It isn’t about the government–it’s about our country.” He was well spoken for a yard man. Read the New York Daily News story for the details.

I suppose we could all learn something from the Lawnmower Man.

“It’s not about Obamacare–it’s about our patients.”

It doesn’t have quite the same ring.

I know I’ve said something like: “Sure patients might have coverage, but who’s gonna provide patient care when Obamacare leads to a physician shortage?”

I’ve also said that the Maintenance of Certification (MOC) and Maintenance of Licensure (MOL) programs will hurt the recruitment effort to attract doctors to practice in Iowa. Who’s gonna provide primary care to patients?

And I’m not the only one who’s said there will never be enough psychiatrists to care for those with both medical and mental illness in primary care clinics.

"Relegating this work entirely to specialists is futile for it is doubtful whether there will ever be a sufficient number of psychiatrists to respond to all the requests for consultations. There is, therefore, no alternative to educating other physicians in the elements of psychiatric methods."

“Relegating this work entirely to specialists is futile for it is doubtful whether there will ever be a sufficient number of psychiatrists to respond to all the requests for consultations. There is, therefore, no alternative to educating other physicians in the elements of psychiatric methods.”–George W. Henry, MD, 1929

I guess that begs the question, if integrated or collaborative care team models are the wave of the future, who’s gonna lead the team?

On the other hand, we can all use a lesson in accountability (and humility) sometimes.

Who’s gonna mow your grass?



  1. Jim, Is seeing a psychiatrist any harder than going to the Mayo Clinic? Here in Minnesota, I live about 80 miles from the Mayo Clinic in the Twin Cities. A few years ago my wife needed a neurosurgical procedure and we had two choices – go with a surgeon in the health plan who had done 9 procedures lifetime or go the the Mayo Clinic with a surgeon who does three of these procedures a day and who published a series of his first 100 cases about 20 years ago. My point here is that there will always be these difficult choices in medicine and access to psychiatry is a thousand fold better than access to specialty neurosurgery.

    Collaborative care versus care “as usual” is a false choice because in my opinion care as usual is suboptimal. The entire “med check” paradigm on the outpatient side and DRG paradigm on the inpatient side needs to be scrapped. Psychiatrists should be collaborating across networks of psychiatrists focused on specific problems. The University of Wisconsin Memory Clinics http://www.wai.wisc.edu/clinics/madison.html paradigm is an example. Not only does this disorder focused model provide education and prevent professional isolation, but it should also automatically count as MOL/MOC credit. State psychiatric societies could organize networks according to the DSM 5 diagnostic categories and psychiatrists in the state could join as many as they want to.

    The bureaucrats and politicians don’t know it but the idea of a psychiatrist monitoring the PHQ-9 scores of 500 patients in primary care is an example of how a profession is dumbed down by administrators. At a recent conference I had the opportunity to listen to the section heads of the DSM 5 and how science and research was actually incorporated into the DSM. You would never know that reading the New York Times. I would make the argument that you don’t need psychiatrists who are researchers if all you are going to do is monitor rating scales. In fact, I would suggest that it means you don’t know much about the science of psychiatry.

    Our direction needs to be 180 degrees away from collaborative care. This is more than a battle about care delivery. This is a battle for psychiatry.


    • George, your point is well taken. I have talked with many patients who simply can’t get access to quality mental health care because they have IowaCare, which is going away. There will be a significant number of Iowans who won’t have access to coverage for any health care in the Health Insurance Marketplace (and may be more likely to use the emergency room) until January 2014 when they’ll be eligible to apply for participation in Governor Branstad’s Iowa Health and Wellness Plan. Psychiatrists are rarer than hen’s teeth in certain rural parts of the state.

      That said, I have administered depression rating scales to patients hospitalized on the medical side of our hospital. The scores may indicate moderate to severe depression. However, when I interview them face to face, some of the patients don’t answer the questions accurately. Sometimes their behavior is not in accord with the rating scale cutoff score. So I agree with your concerns about rating scales. They are points of departure, not the whole journey. I would not expect a primary care clinician or mental health case manager to do what I do as a diagnostician. They are more likely to take the raw scores on the PHQ-9 or other such tool at face value, which is more likely to overestimate the occurrence rates of depression. As a consequence of the shortage of psychotherapists (psychiatrists and psychologists), overprescription of antidepressants will also probably be more likely.


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