Changing The Three Legged Stool

Last week I got great news from the Chair of the Department of Psychiatry, Dr. Kolin Good, MD at Reading Hospital in Reading, Pennsylvania.

They just opened their own medical-psychiatry unit after 5 years of hard work and consultations with The University of Iowa Hospitals and Clinics. My role was to acquaint the Reading leadership with my view of the clinical issues involved in running such a unit, which, Dr. Roger Kathol, MD, a former teacher of mine, prefers to call a Complexity Intervention Unit (CIU).

The Reading team prefers “Medical Complexity Unit.” It currently has 12 beds and will eventually have 19, possibly just in the next month or so. It’s a critically important step in the long evolution toward integration of inpatient medical and psychiatric care. That kind of work for change takes tenacity.

Way back when I was an undergraduate at Huston-Tillotson College (now Huston-Tillotson University) in Austin, Texas, I learned about tenacity to principle and practice from a visiting professor in Sociology (from the University of Texas, I think) who paced back and forth across the Agard-Lovinggood auditorium stage in a lemon yellow leisure suit as he ranted about the importance of bringing about change. He was a scholar yet decried the pursuit of the mere trappings of scholarship, exhorting us to work directly for change where it was needed most.

He didn’t assign term papers, but sent me and another freshman to the Austin Police Department. The goal evidently was to make them nervous by our requests for the uniform crime report, which our professor suspected might reveal a tendency to arrest blacks more frequently than whites (and yes we called ourselves “black” then). He wasn’t satisfied with merely studying society’s institutions; he worked to change them for the better. I remember him whenever I’m frustrated about the glacial process of change.

Many people have called for change in the way psychiatrists work, often toward greater integration with medicine. One article published about 5 years ago (about the time Dr. Good called us in fact) in Psychiatric News by Dr. Andres Barkil-Oteo, MD, M.Sc, titled “Can a Three-Legged Stool Save Psychiatry?” mentioned the seemingly endless identity crisis psychiatry seems to have. He suggested we think of it as a three-legged stool, with access, diagnosis, and treatment as the three legs. He was referring to the chronic problems even getting in to see a psychiatrist in less than several months (if at all), the curious problem of about half of all people getting mental health treatment having no psychiatric diagnosis, and the dismally low treatment rate and the ineffective treatment practices.

Dr. Barkil-Oteo goes on to describe the collaborative care model as the best answer to the three-legged stool problem, helping to integrate medical and psychiatric care, saying:

Collaborative care—providing mental health services in primary care clinics—should become one of the main activities for psychiatrists. Two-thirds of primary care physicians reported in 2004–2005 that they could not get outpatient mental health services for patients—a rate that was at least twice as high as that for other services. While there are many obstacles, including rigid financial compensation schemes and outmoded billing practices, models for success, such as the University of Washington’s IMPACT program and others that implement psychiatry in primary care, have proved that it can be done.

These models could potentially target all three legs of the stool. Unützer, Katon, and colleagues showed that such models improve access to mental health services by using patient registries and adopting a population-based mental health perspective. Diagnosis can be improved through supporting primary care doctors in identifying and treating psychiatric disorders and having psychiatrists making direct consultations to the clinic.

One of the issues with the collaborative care model is having to spend most of the time doing curbside consults on the phone with a care manager who is the middle man between the psychiatrist and the primary care doctor. Most of us got into psychiatry to talk face to face with patients.

And then there’s this–I saw a recent letter to the editor in Clinical Psychiatry News from a Manhattan psychiatrist, Dr. Glenn Losack, MD, who has a very different view of what psychiatrists ought to be doing. It’s provocatively titled, “How to save psychiatry.” He reminds readers about the shortage of psychiatrists and recommends locum tenens and telepsychiatry as potential solutions. He’s worried that the growing workforce of nurse practitioners and physician assistants might take the gloss off becoming a psychiatrist and discourage new applicants. He then says that we need to shorten the residency training period to two and a half years partly because, as he puts it:

Four years is a waste of time–and times have changed. After all, we are not doing psychotherapy, per se. That 4th year could be deleted, and instead, a psychiatrist could be earning close to $200,000 instead to pay back loans.

Sound good? Before you criticize it, you should know that he’s done pretty well financially. He was able to semi-retire when he was 40. On the other hand, the recommendation for postgraduate training that would allow psychologists to prescribe in Iowa is also only two years. Governor Branstad signed that bill into law in May of 2016. No word yet on when it will be implemented. I’m not sure I understand how Dr. Losack’s suggestion to cut the residency training of a psychiatrist would boost the incentive to become one in this context.

I wonder if we need to consider a different kind of three-legged stool to promote the idea that becoming a psychiatrist in today’s health care environment, in today’s economy, and in today’s culture should still be a calling, not just a job. Maybe it should be the three-legged stool you sit down on, in order to listen to your patients and your colleagues, try to understand them, and to help them.



Title: Can a Three-Legged Stool Save Psychiatry? (Viewpoints)

Author: Andres Barkil-Oteo, MD, M.Sc

Publication: Psychiatric News (Magazine/Journal)

Date: September 21, 2012

Publisher: American Psychiatric Association

Volume: 47     No: 18


Title: How to save psychiatry (Letter to the editor)

Author: Glenn M. Losack, MD; New York

Publication: Clinical Psychiatry News (Magazine/Journal)

Date: August 2017

Publisher: Frontline Medical Communications Inc.

Volume: 45     No: 8   Page: 6

2 thoughts on “Changing The Three Legged Stool

Comments are closed.