STOP and Think: The Challenge of Complexity for New Leaders

I just saw an article in Psychosomatics about bipolar disorder prevalence in primary care that made several issues come together for me, including the resident leadership committee on which I’m serving. The article was a systematic review and the major conclusion was that the Mood Disorder Questionnaire (MDQ) is probably not the best choice for primary care physicians to use in identifying bipolar disorder.

While that may seem painfully obvious, there’s a context for my concern. So why even think about this and why is it an issue for cultivation of residency leadership? Let’s look at it as a sort of STOP sign, with the main message being “stop and think it over”, not “stop thinking.”STOP and THINK Complexity

Even psychiatrists have a difficult time with overdiagnosis of bipolar disorder, so why are we expecting primary care physicians to manage it? A little over a year ago, there was an article in Clinical Psychiatry News in which the author described the Centers for Medicare and Medicaid Services (CMS) proposed Clinical Quality Measure (CQM) which could have made it mandatory for non-psychiatric clinicians to screen all patients annually for depression in order to receive financial incentives and, in 2015, to avoid financial penalties. That could mean patients screening positive for depression who might in fact have bipolar disorder would potentially be harmed by treatment with antidepressant. So CMS creation of CQMs could directly influence psychiatric treatment in the primary care clinic.

I have no idea where this issue stands now with CMS (and maybe a top-flight leader would), but bear in mind that CMS, in conjunction with the Affordable Care Act (ACA) law, created the PQRI financial incentives to physicians who participate in Maintenance of Certification (MOC). In connection with that, beginning in 2014, “physicians who do not submit measures to PQRI will have their Medicare payments reduced.” This is taken directly from a condensed version of the ACA, http://www.dpc.senate.gov/healthreformbill/healthbill53.pdf. So CMS could still provide incentives to primary care clinicians to try to assess and manage not just depression, but bipolar illness.

The influence of MOC in this arena can be seen on the American Board of Psychiatry and Neurology (ABPN) web site where you can find the Performance in Practice (PIP) modules.

There you can see the NOW Coalition for Bipolar Disorder, which is an ambitious project to teach primary care physicians and psychiatrists how to assess and treat bipolar disorder. The drawback that I see is that it seems to promote the use of the MDQ screening instrument, exactly what Cerimele et al caution us against doing. I would think a leader could have seen that one coming.

Note the final author on the Cerimele et al paper–Dr. Wayne Katon, MD, who is one of the nation’s leaders on collaborative care interventions in primary care. It’s not coincidental that the “Conclusions and Future Directions” section includes the statement, “Team approaches involving integrated psychiatric and primary care may improve the management of complex primary care patients such as patients with bipolar disorder. Future research could address the optimal treatment for primary care patients with bipolar disorder, and address which patients can be effectively treated in primary care.”

And CMS is fostering the move from volume-based payment incentives to those rewarding integrated care models at the state level whose goal is to improve health care quality. Another governmental influence toward integrated care comes from the Senate Finance Committee and House Ways and Means Committee in the form of legislation. This would replace the sustainable growth rate (SGR) payment program with a “value-based performance” payment. I don’t pretend to be an expert on the SGR, but it’s impossible not to hear almost every day about this hated piece of the Medicare payment formula.

What we often don’t acknowledge is the problem of the physician shortage, which is both driver and brake on the momentum of integrated care programs. Primary care physicians have, on average, about 10 minutes to spend with each patient, and there are never enough psychiatrists available, a major reason cited for moving psychiatric care to the primary care clinic–long wait times to get in to the psychiatry clinics. What might be an unintended consequence of the ACA is the exacerbation of the physician shortage, with more patients getting insurance coverage than there are doctors to care for them.

How does Maintenance of Licensure (MOL) fit in? MOL would tied medical licensure to compliance with MOC. MOL is a second cousin of MOC, as everyone knows who has discovered that the Federation of State Medical Boards (FSMB) notes you could substantially satisfy the requirements for MOL by participating in a MOC program or one like it. Many physicians object to MOL while supporting lifelong learning. Several state medical societies have adopted resolutions opposing MOL. In my opinion, MOL would exacerbate the physician shortage still further because I suspect it will make physician recruitment more difficult, especially in physician shortage areas.

Finally, patient preference is critically important. Integrated and collaborative care programs are often popular with patients with comorbid depression and chronic medical illnesses, the outcomes for which are often excellent using these models. However, we fail to account for the range of preferences which exist. One of them which is almost always ignored is the preference to see a specialist rather than a primary care doctor for complex psychiatric conditions the management of which primary care clinicians are ill-equipped to assume.

This all has the feel of a runaway train, and it’s impossible not to stop and think about all the implications for the education and training of psychiatry residents, particularly in leadership cultivation. As I pointed out at the top of this post, I’m on a committee focused on improving the opportunities for resident leadership both within our residency program and at state and national levels. I’m looking for ways to define leadership for trainees and I get a little tired when I think of the myriad pressures facing them. I’m not sure how helpful it was to read the American Psychiatric Association (APA) President’s message.

It’s daunting to read just how complicated it’s going to be just to educate the general psychiatry resident, let alone cultivate the next generation of leaders. The clarion call for champions of the integrated care models is in there, as is the push for greater emphasis on neuroscience education. I’m not so sure yet exactly how the ACGME Psychiatry Milestones project will foster this effort. I know that it reads an awful lot like the MOC…so I’m thinking we’re already off on the wrong foot.

So what’s the best way to cultivate leadership in psychiatry residents, given all of this complexity? Well, even though I’m not a resident anymore, I can personalize this as a lifelong learning issue for me. First, I have to know that the complexity exists. I guess it’s also worthwhile to know, as Stephen Covey outlined, what issues lie inside my “circle of influence” which ones lie within my “circle of concern.”

Admittedly, I could do a better job with that. But I can also broaden my circle of influence, maybe by broadening the circle of people I know, books I could read, and maybe ironically, shrinking my circle of attention so that I spend more time looking at the change that needs to happen from the “inside out.”

I’m really glad the residents are smarter than I am.

Reference:

Cerimele, J. M., et al. (2013). “The prevalence of bipolar disorder in primary care patients with depression or other psychiatric complaints: a systematic review.” Psychosomatics 54(6): 515-524.
BACKGROUND: Bipolar disorder prevalence in primary care patients with depression or other psychiatric complaints has been measured in several studies but has not been systematically reviewed. OBJECTIVE: To systematically review studies measuring bipolar disorder prevalence in primary care patients with depression or other psychiatric complaints. METHODS: We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method in January 2013. We searched 7 databases using a comprehensive list of search terms. Included articles had a sample size of 200 patients or more and assessed bipolar disorder using a structured clinical interview or bipolar screening questionnaire in adult primary care patients with a prior diagnosis of depression or had an alternate psychiatric complaint. RESULTS: Our search yielded 5595 unique records. Seven cross-sectional studies met our inclusion criteria. The percentage of primary care patients with bipolar disorder was measured in 4 studies of patients with depression, 1 study of patients with trauma exposure, 1 study of patients with any psychiatric complaint, and 1 study of patients with medically unexplained symptoms. The percentage of patients with bipolar disorder ranged from 3.4%-9% in studies using structured clinical interviews and from 20.9%-30.8% in studies using screening measures. CONCLUSIONS: Bipolar disorder likely occurs in 3%-9% of primary care patients with depression, a trauma exposure, medically unexplained symptoms, or a psychiatric complaint. Screening measures used for bipolar disorder detection overestimate the occurrence of bipolar disorder in primary care owing to false positives.

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Comments

  1. Psych Practice did a wonderful job on the STOP logo!

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  2. This is another example of bad decision making by the political system in this country. Politicians generally know very little about medicine, science, statistics, or business. It is painfully obvious that they know nothing about psychiatry. They have even blown obvious political decisions as evidenced by three unnecessary wars in my lifetime. Part of the problem is that physicians either think that they are above politics or don’t have to engage at that level.

    Time to rally around the STOP sign.

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  3. Jim – Outstanding post. You have illuminated the central fallacy of “population based medicine” which in turn is the basis for these screening device approaches to collaborative care. You don’t even need to be a skeptic to realize that you can’t provide complex care by dumbing down the process and there is no dumber way to do that than suggest that the MDQ equates to a diagnosis of bipolar disorder. It reminds me of a business manager who called me out of the blue a few years ago. His concern was that one of his employees went into a primary care clinic because of concern about depression and came out with a diagnosis of bipolar disorder in about 20 minutes. In addition to the diagnosis there were three prescriptions for divalproex, an antidepressant, and an atypical antipsychotic. The manager wanted to know if it was possible to make a diagnosis of bipolar disorder in 20 minutes. Looking back on that I suppose you could hand out the MDQ and spend 20 minutes talking about medications.

    Somebody has to start to seriously question this process. There is no other field where this would be accepted. Should we not teach calculus because it is more cost effective for everyone to know simple arithmetic? Should middle aged patients with chest pain in the ED get a checklist to determine whether they are admitted for what is typically a $20-40K work up? There is no better example of diagnostic complexity in psychiatry than bipolar disorder. I am an expert in the diagnosis and treatment of bipolar disorder and using the best techniques elaborated in Chisholm and Lyketsos it can take me anywhere from 90 minutes to 5 hours to figure out what is going on. Even then I need to talk with collateral sources.

    With the obvious diagnostic problems, there also seems to be a general cluelessness about the severe limitations of rating scales in psychiatric practice. There seems to be a confluence of interests from collaborative care, evidence based care, and managed care pushing this experiment. It seems to me that there is less evidence for this approach than there was for the abandoned dexamethasone suppression test in the 1990s. If that test had come out today, I could see it being promoted right there with the PHQ-9. There is nothing like a simple solution to a complex problem.

    Your stop sign logo is excellent. I would suggest coming up with a slightly more stylized version, but retaining all of the elements and putting up a downloadable version for psychiatrists everywhere to link to on the Internet. It can be a rallying point for all of these issues.

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  4. There are so many problems, I just want to cry. Or quit.

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