Thanks for the Memories

What a moving scene.

Because of construction on the new Stead Children’s Hospital, several of us have to move out of our offices for the next month. It gave me a chance to once again discover how much useless junk I can accumulate. It was enough to require a big blue bin on wheels. I’ve used it before. What stuff remained fit into only 4 packing boxes. My office looks pretty bare now. I imagine that’s how it will look on the day I retire. I see this temporary move as a way of getting prepared for that, so I’m ahead of the game now.

I didn’t have to take down any pictures or certificates. I don’t really spend a lot of time in my office because I’m a general hospital psychiatrist, a smokejumper putting out fires, so to speak, all over the hospital. A big part of my job is triage, as the medical students soon learn. I organize transfers from inpatient medical-surgical units to inpatient psychiatric wards, either the medical-psychiatry unit (the only one of its kind in the region) or the general psychiatric units.

Triage implies that the psychiatry consultation service is a kind of traveling  Mobile Army Surgical Hospital (M.A.S.H.) unit–meatball psychiatry. I patch them up and send them on where further healing can take place. That’s the hope. Rarely do I get feedback from my colleagues staffing the psychiatry inpatient units although when I do I really appreciate the perspective it gives me. But it’s only a part of what psychiatric hospitalists do. In a few places, the liaison part of what we used to call Consult-Liaison Psychiatry (C-L Psychiatry for short) is starting to make a comeback:

It’s a moving on which is, at the same time, a sort of moving back because that’s historically how C-L Psychiatry got started a long time ago (actually before my time, if you can believe that). And as my medical students and residents do their own moving on to the next rotation and the next stage in their journey, we are wishing each other well. The group picture is becoming a ritual, a sort of rite of passage.

Group Picture on the CL Service April 28, 2016.
Group Picture on the CL Service April 28, 2016. Now there’s a group! Those weird objects are the mascots-and I don’t mean the trainees.

Dr. Darbie Little-Cooper, the senior in her 5th year of the Family Medicine-Psychiatry residency program, came up with something even better:

Happy Last day - Microsoft Word_2016-04-29_10-31-24
Consult-teers left to right: Dr. Mary Haas (Family Medicine resident), Dr. Suchita Batwara (Internal Medicine-Psychiatry resident), Dr. Darbie Little-Cooper (Family Medicine-Psychiatry resident); can’t touch this.
Core Competency Pizza
Core Competency Pizza

I rant and rave to the trainees about our health care system and ask them to remember my affect. I’m hoping they will. However, I’m all for evidence-based medicine and the core competencies and I tell them that. On the other hand, I was a little skeptical when I got a message in my email that invited me to read a white paper entitled “Why Evidence-Based Medicine?”

“Evidence-based medicine (EBM) is an ongoing and burgeoning field that has now become the norm in today’s practice of medicine. It involves a systematic approach to clinical problems aimed at identifying strategies that work and eliminating those that do not work, are harmful, or are proven to be not beneficial based on research evidence. The white paper Why Evidence-Based Medicine? provides the background needed to successfully implement evidence-based medicine in any healthcare setting, and gives the tools required to:

By implementing these strategies, healthcare professionals will join a movement to promote consistency of treatment and optimal outcomes, help establish national standards of patient care, and set criteria to measure and reward performance-based medical practice.

  • Translate a patient clinical problem into a well-structured question
  • Phrase that question to facilitate an evidence-based solution search
  • Conduct EBM searches in national databases, guidelines, and journal articles
  • Test evidence for validity, applicability, and clinical relevance
  • Apply the evidence and evaluate its performance

For more information, please visit McGraw-Hill Education’s Professional Insights blog.

McGraw-Hill Education has created the Professional Insights blog, a community for clinical, educational, and professional thought-leaders to gather and share their knowledge. From tips on fostering better collaboration amongst teams to advice on handling budget concerns, the McGraw-Hill Professional Insights blog has the answers you’re looking for. Visit us often for the latest news, strategies, and advice.

I’m not criticizing McGraw-Hill at all; the white paper is probably excellent. On the other hand, I’m a geezer and I get a little more skeptical with each passing year. So I looked up “evidence-based medicine” for myself on PubMed and found an article entitled “Evidence based medicine: a movement in crisis?” I didn’t read “Why Evidence-Based Medicine” because when I clicked on “Download White Paper” hyperlink I got a message with my contact information on it and a notice indicating that by so doing I would be opening myself up to further messages–which I might not want. It sounded like they might be trying to sell me something so instead I read “Evidence based medicine: a movement in crisis” because I know up front it’s free. You can figure out why I disabled the hyperlinks.

I like the authors’ tone because it sounds skeptical and because they think critically about what’s happening in medicine. I wish I were as articulate as they are when I try to convey this to my trainees. I think the boxed summaries of the critical points are important to remember:

Box 1: Crisis in evidence based medicine?

  • The evidence based “quality mark” has been misappropriated by vested interests
  • The volume of evidence, especially clinical guidelines, has become unmanageable
  • Statistically significant benefits may be marginal in clinical practice
  • Inflexible rules and technology driven prompts may produce care that is management driven rather than patient centred
  • Evidence based guidelines often map poorly to complex multimorbidity

Box 2: What is real evidence based medicine and how do we achieve it?

Real evidence based medicine:

  • Makes the ethical care of the patient its top priority
  • Demands individualised evidence in a format that clinicians and patients can understand
  • Is characterised by expert judgment rather than mechanical rule following
  • Shares decisions with patients through meaningful conversations
  • Builds on a strong clinician-patient relationship and the human aspects of care
  • Applies these principles at community level for evidence based public health

Actions to deliver real evidence based medicine

  • Patients must demand better evidence, better presented, better explained, and applied in a more personalised way
  • Clinical training must go beyond searching and critical appraisal to hone expert judgment and shared decision making skills
  • Producers of evidence summaries, clinical guidelines, and decision support tools must take account of who will use them, for what purposes, and under what constraints
  • Publishers must demand that studies meet usability standards as well as methodological ones
  • Policy makers must resist the instrumental generation and use of “evidence” by vested interests
  • Independent funders must increasingly shape the production, synthesis, and dissemination of high quality clinical and public health evidence
  • The research agenda must become broader and more interdisciplinary, embracing the experience of illness, the psychology of evidence interpretation, the negotiation and sharing of evidence by clinicians and patients, and how to prevent harm from overdiagnosis

Anyway, thanks for the memories!


APM Annual Meeting 2015 Highlights: Day 5

Last day for us. Yesterday evening I attended the session “Medical Psychiatric Inpatient Integrated Care Models: History, Challenges and Benefits Shared by Four Institutions.” My colleagues Dr. Vicki Kijewski and Dr. Gen Shinozaki were presenting and moderating, respectively.

It was very interesting to learn of the other methods that exist to approach the challenge of providing concurrent medical and psychiatric care rather than fragmented, sequential kind so typical of our present system.

Dr. David Hilden (internal medicine hospitalist) of Hennepin County Hospital in Minnesota described their solution of embedding internal medicine hospitals in the psychiatric units, providing 365/24/7 acute medical care for psychiatric inpatients. The hospitalists who attend on the units do it because they enjoy it…they need no other incentive.

Yes, Virginia; there really is a Santa Claus!

The representatives from Hackensack University Medical Center described a very cost-effective solution with a medical-psychiatry unit that provides a clearly integrated approach which is strongly supported by hospital administration. They’ve been successfully implementing the program for about the last 10 years.

Dr. Vicki KijewskiDr. Kijewski delivered a detailed summary of our hospital’s 15 bed medical-psychiatry unit (or complexity intervention unit a term preferred by the founder, Dr. Roger Kathol), really the only unit of its kind in the region.

Representatives from Long Island Jewish Medical Center discussed the pros and cons (most successful also, in my humble opinion) of their own solution with a collaborative team approach making practical use of very experienced nurses already familiar with a holistic and patient-centered care approach.

One of the common features from several of the presenters is the success of case conferences which engage learners at every level from medical student t0 faculty member.

What’s apparent from all of their systems is now closely knit they are interpersonally and professionally. Selling the idea of integrated medical-psychiatry inpatient units was complicated and an uphill battle for many of us. I think these systems prevail, not so much on whether or not they’re cost-effective–but because the clinicians, nurses, social workers, and other stakeholders believe passionately that what they provide for patients truly helps them heal.

Bits and pieces:

Although they had daily Mindfulness Meditation sessions here, I didn’t go because they started at 6:15 in the morning and I do my mindfulness practice in the evenings, even here in this over–furnished hotel room.

Yesterday, I got a “Final Notice Alert” from the Clozapine REMS Program about somebody else’s patient. I wonder what happens after the “final notice”?

The APM meeting was about much, much more than what I’ve outlined here in the past few days. All I could give you was a bare glimpse of what I have experienced. There are many concurrent workshops going on all hours of the day. You really can’t get a feel for it unless you attend. You could join, in fact.

Just remember; once you become a member…you’re in it for life because there’s no getting out

I’m on my way to the presentation “Doc to Doc: Maximizing the Impact of Consultation Documentation,” led by Drs. Jeanne Lackamp, Vicki Kijewski, and Zafar Zaidi.

Collaborative and Integrated Care: Dr. Lori Raney, M.D.

This is another perspective on the integrated care vs collaborative care definitions by an expert in the field, Dr. Lori Raney. Her perspective tend to simplify the issue.

Dr. Raney was also one of those offering constructive tips on the Frequently Asked Questions (FAQ) section of a recent Psychiatric News Alert about Integrated Care FAQs.

If integrated care is the wave of the future for psychiatrists, I wonder what form it will take in different parts of the country. In some primary care clinics, there will certainly be a role as long as psychiatrists can figure out how they’ll get paid and won’t be marginalized. It’s a little hard for me to see how psychiatrists can take a leadership role in the collaborative arrangement if they’re not actually seeing the patients and the primary care physicians are doing the prescribing and behavioral health specialists are implementing the non-pharmacologic psychosocial interventions.

I think what might lead to a sense of isolation for the psychiatrist is the part about going over the care manager’s case load once a week or once a month by telephone. Even the psychiatrist’s note will have to contain language which makes it clear that he or she did not actually do a face-to-face assessment. A disclaimer might read like the following:

My treatment observations and suggestions are based on telephone consultation with the mental health care manager and chart review only. All pharmacologic and behavioral treatment recommendations should be carried out with the patient’s current clinical status in mind and include the patients preferences when possible.

It raises questions about liability and whether the primary care physician or the psychiatrist is actually in the best position to be the team leader.

Payment for psychiatric consultation could be problematic, as Dr. Jurgen Unutzer, MD admits in the FAQ. if someone could explain to me how the system would work with insurers currently in our state’s Health Insurance Marketplace, I’d feel more confident about collaborative care. Our largest insurers, Wellmark Blue Cross and Blue Shield,  and United Healthcare, are not yet enrolled in the Health Insurance Marketplace, yet serve more than 85% of the Iowa market. I’m not sure how or if Wellmark would pay for a collaborative care arrangement. And I’m unsure if the other 10 carriers who filed plans in the marketplace would either. This information about the players in the market comes from a previous post.

That said, I think there’s potential for improvement in the care of populations of patients, probably focusing on primary care. I sometimes wonder how it might work in our newest outlying clinic, the Iowa River Landing (IRL).

As it is there is no psychiatrist for emergencies and one would have to call 911, similar to most outlying medical clinics in many communities. Would a collaborative care approach help cut down on the stress and confusion of psychiatric emergencies, say suicide ideation? If a team-based model were applied and higher risk patients were being monitored by a care manager and a consulting psychiatrist, this might be achievable.

On the other hand, I get a little worried about the reliance on checklists like the PHQ-9 as the main outcome measure. I’ve always thought of psychiatric rating scales, especially self-rating instruments, as points of departure rather than the whole journey. I tend not to think of screening tools as diagnostic instruments. Very often, I’ve found them to be inaccurate, often overestimating depression. The best diagnostic instrument is an experienced, thoughtful, and methodical clinician who is able to see and talk with the patient.

However, in the world of the physician shortage, which will probably worsen with the Affordable Care Act as more people obtain insurance coverage and the number of patients exceeds the supply of doctors who can provide care–a population based care model in which a psychiatrist could reach more people through the care manager might make sense.

Integrated Care Marginalizing Psychiatrists or Optimizing Access to Psychiatric Treatment?

So I ran across this interesting article in the June 2013 issue of Clinical Psychiatry News about collaborative care, which showed improved response for patients suffering from late-life depression [1]. The results of a records review of Patient Health Questionnaire (PHQ)-9 of 186 older adults enrolled in the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) collaborative care project, started in March of 2008, were presented at the American Association for Geriatric Psychiatry (AAGP) annual meeting.

After six months of treatment, mean PHQ-9 scores were significantly lower for the 93 patients in the DIAMOND group than for the 93 patients in the usual care group. Antidepressant medication use was similar in both groups. The findings also showed antidepressant use was not increased using the collaborative-care model. This is a concern I’ve heard raised by some psychiatrists. Another is that psychiatrists will ultimately be further marginalized than we already are, a point raised at the November 2012 annual meeting of the Academy of Psychosomatic Medicine (APM) meeting in Atlanta, Georgia. I posted about this, which you can review at link, Clinical Excellence in Psychiatry and Integrated Care: Can We Have Both? – The Practical Psychosomaticist.

According to the Worcester article, “Collaborative-care models that bring primary care providers and psychiatrists together to care for patients have been shown in numerous studies to be more effective than usual care for the management of depression.”

The model involves a primary care manager and a “liaison or consultative relationship with a psychiatrist…” Programs like DIAMOND provide consistent assessments and follow-up, using a population-based registry to track treatment response over time. I’m going to warn readers ahead of time that, although I’ve written in enthusiastic praise of integrate care models in the past, I’ve heard other physicians raise doubts about it that have made me think a little harder.

A legitimate question some psychiatrists have is how these collaborative-care models are going to be funded after the research programs which currently support them end their support. Others believe that psychiatrists are being marginalized to the point of near-extinction. However, a recent Journal of the American Medical Association (JAMA) interview with a major research leader in integrated care models, Wayne Katon, MD, may not support that concern [2]. Dr. Katon is a psychiatrist, I’ve heard him speak many times at Academy of Psychosomatic Medicine (APM) meetings, and I doubt he would engage in this field of research if he thought it would marginalize psychiatrists. In fact, in the JAMA article he says,Wayne Katon, MD

“We don’t want psychiatrists to be left behind in the changes that are rapidly going on. Many psychiatrists are involved in efforts to integrate mental health services into primary care and medical specialty care as well as collaborative care and dissemination trials.” True, he doesn’t specify how psychiatrists will not be left behind.

Dr. Katon mentions the three main elements in collaborative care, which are “population-based care, measurement-based care, and integration of psychiatry expertise into primary care.”

A fair criticism, though, of measurement-based care as it occurs in primary care clinics is that the favored tool, the PHQ-9, may tend to overestimate the severity of depression, according to Zimmerman and colleagues [3].

Moreover, a recent U.S. survey shows depression is overdiagnosed and overtreated [4].  The study looked at whether patients identified by their clinicians also met the DSM-IV criteria for 12 month major depressive disorder. Out of over 5,600 patients with clinician-identified depression, only about 38% met diagnostic criteria for major depression. Study author Dr. Ramin Mojtabai of Johns Hopkins said, “This finding highlights the growing trends in prescription and use of psychiatric medications, and especially antidepressants, in the USA, even in the absence of a psychiatric diagnosis.”

It remains to be seen whether the physician shortage will lead to the dwindling number of primary care physicians to refer patients to psychiatrists sooner because of being overwhelmed by the increasing numbers of patients ushered in via the Affordable Care Act–and consequently expand the already large wait list to get into undermanned, overworked mental health clinics. Alternatively, what we could see are an overwhelming number of patients taking psychiatric drugs whether they need them or not.

Integrated care can be a double-edged sword and could mean greater access for patients with better treatment of psychiatric illness or greater marginalization of psychiatrists and overmedicalizing of sorrow, grief, and reactive, temporary sadness which could ultimately be a growth experience for many. I guess I don’t what to say…yet.


1. Worcester, S. (2013). Collaborative care improved response in late-life depression. Clinical Psychiatry News, IMNG Medical Media. 41.

2. Kuehn, B. M. (2013). “Health reform, research pave way for collaborative care for mental illness.” JAMA 309(23): 2425-2426.

Wayne Katon, MD, professor of psychiatry at the University of Washington in Seattle, has worked to develop and test models for integrating mental health care into primary care practice for the past 30 years. For much of that time, dissemination of the model moved slowly, but this process has been rapidly accelerated by health reform and growing recognition of the benefits of integrated care. Katon discussed the future of the model with JAMA.

3. Zimmerman, M., et al. (2012). “How can we use depression severity to guide treatment selection when measures of depression categorize patients differently?” J Clin Psychiatry 73(10): 1287-1291.
OBJECTIVE: Treatment guidelines for depression suggest that severity should be taken into account when initiating treatment. If clinicians are to consider illness severity in selecting among treatment options for depression, then it is important to have reliable, valid, and clinically useful methods of distinguishing between levels of depression severity. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared 3 self-report scales that assess the DSM-IV criteria for major depressive disorder on the basis of how these scales distribute patients into severity categories. METHOD: From June 2010 to November 2011, 245 depressed outpatients completed the Clinically Useful Depression Outcome Scale (CUDOS), Quick Inventory of Depressive Symptomatology (QIDS), and Patient Health Questionnaire (PHQ-9). The study was conducted at Rhode Island Hospital, Providence, Rhode Island. The patients were subdivided into severity categories according to the cutoff scores recommended by each scales’ developers. The patients were also rated on the 17-item Hamilton Depression Rating Scale (HDRS-17). RESULTS: The correlations between the HDRS-17 and the 3 self-report scales were nearly identical. Yet the scales significantly differed in their distribution of patients into severity categories. On the CUDOS and HDRS-17, moderate depression was the most frequent severity category, whereas on the PHQ-9 and QIDS, the majority of the patients were classified as severe. Significantly fewer patients were classified as severely depressed on the CUDOS compared to the PHQ-9 (McNemar = 153.8; P < .001) and QIDS (McNemar = 114.0; P < .001). CONCLUSIONS: If clinicians are to follow treatment guidelines’ recommendations to base initial treatment selection on the severity of depression, then it is important to have a consistent method of determining depression severity. The marked disparity between standardized scales in the classification of depressed outpatients into severity groups indicates that there is a problem with the use of such instruments to classify depression severity. Caution is warranted in the use of these scales to guide treatment selection until the thresholds to define severity ranges have been empirically established.

4. Rajaraman, M. (2013). U.S. survey shows depression overdiagnosed, overtreated. Clinical Psychiatry News, IMNG Medical Media. 41.

The Medical-Psychiatry Unit: The Moment Has Arrived

MPUA complexity intervention unit (CIU) is a specialized inpatient unit for managing patients with complex, comorbid medical and psychiatric diagnoses as well as health care system and social issues that make it challenging to deliver the highest quality health care. I still like to call it a “medical-psychiatry unit” (MPU) even though my old teacher, Dr. Roger Kathol, prefers “CIU”. You’ll find “CIU” all over his web site, Cartesian Solutions – Care Delivery Systems.

Roger G. Kathol, M.D., C.P.E.
Roger G. Kathol, M.D., C.P.E.

You will also find the term mentioned on the Academy of Psychosomatic Medicine (APM) web site, where it counts as  one of the most important interventions in the wave of the future of integrated care systems, Health Reform: Toolkit for Promoting PM. Dr. Kathol created the MPU here at The University of Iowa Hospitals and Clinics (UIHC) in the 1980s. It is highly respected and the most popular model we all point to as the best example of how to provide integrated care in a hospital setting. Hospital representatives from around the country and lately, from over seas as well, travel here to learn how to implement the MPU in their own systems. And it’s a great training setting for learners in the Medicine-Psychiatry Residency Program, Internal Medicine-Psychiatry Residency.

Just for fun, I did web searches for “complexity intervention unit”. Can you guess what I found at or near the top of the hit list, using Safari, Firefox, Google Chrome, and Bing? If you guessed my name, you guessed right. I prefer the name “MPU” to “CIU”, so I’m not sure why it looks like I’m the only one talking about it, according to the world-wide web.

I’ve also got a couple of YouTube videos about the MPU on my YouTube channel, James Amos – YouTube. You can see another video about it at link, Still Enthralled – The Practical Psychosomaticist. I worked as a co-attending on the MPU here at UIHC for about 17 years. I can tell you, in my opinion, it’s the best way to provide excellent clinical care to patients who have complex, comorbid psychiatric and medical problems.

The remarks above are to reinforce my support of the MPU, just in case anyone doubts that after I point out some of the practical challenges to making this square peg work in the round hole of our present health care delivery and payer systems. The MPU concept has always been ahead of its time. Many of us who have been in the trenches have known that. However, now could be the best time for patients, clinicians, insurers, and health care policy-makers to make the integrated care model the law of the land. There has never been a greater need for it when we consider the skyrocketing health care costs in America, compared to other nations.

Here are some of my thoughts about what might make the MPU more widely adaptable and readily adopted.

large_PayingforHealthInsuranceThe current payer system is at the top of the list of what needs to change. Practically speaking, depending on the physician’s specialty, insurers may bill only for a single medical problem per physician per day. In fact, in the model in which a doctor, board-certified in both internal medicine and psychiatry staffs the unit, psychiatry billers may not even submit a bill. In a co-attending model, a general psychiatrist may submit bills for managing the psychiatric disorder, while an internist bills for the medical side.  But in some academic medical centers, the internist need only co-sign a trainee’s notes. On the other hand, the psychiatrist must create notes for each and every patient on the unit, and on average the patient census can be 12 or more. If the fragmented, siloed billing and documentation practices could be replaced by a smarter system, this would attract more general psychiatrists to work in MPUs. This isn’t such a far-fetched notion these days, because there is a push to develop alternative payer systems in this age of research showing the effectiveness of integrated care systems that are population-based.

sleep deprivedThere can be a lot of wear and tear on physicians who must triage patients for admission to the MPU. It is unrealistic to expect combined-specialty physicians and general psychiatrists to do 24/7 call from 8:00 AM to 8:00 AM for weeks at a time. Methods to spread this responsibility around many physicians would go a long way toward improving quality of life for doctors, for whom burnout can be a reason to leave a practice. The task of triage cannot be relegated to trainees or nurses because of the extensive knowledge one must have about the medical, psychiatric, and legal issues involved in the admission process to a locked MPU. The organization of a rational triage system is currently being emphasized at UIHC, where the MPU has been championed for many years.

collaborating docsA close working relationship with all medical professionals who believe their patients might benefit from admission to an MPU is essential. Patients are candidates who have both acute, active medical and psychiatric problems and whose behaviors make it a potentially unsafe proposition for management on an open general medical or surgical unit. It can be unwise to admit patients who have little more than placement issues and who have chronic behavioral challenges that don’t require management on a locked unit. This would tend to fill beds, leaving none available for the patients who need them most. While delirium can be an appropriate indication for admission, not all patients who are delirious need an MPU. In fact, Delirium Prevention Programs run by teams of health care professionals, including a specialist in Psychosomatic Medicine, an internist or family medicine provider, clinical pharmacists, and nurses can help manage the problem of delirium in the general hospital. A Delirium Prevention Program has been in place since 2011 here at UIHC. You can read more about its growing pains at Delirium Project Chronicle – The Practical Psychosomaticist.

These are just some of my thoughts about the MPU, an idea that has always been ahead of its time… and now the time is right for it to truly fly.

Still Enthralled

I got into this video somehow about the Medical-Psychiatry Unit (MPU). The star, Maritza, was gently insistent about it. I was on walk rounds with the rest of the team, seeing, smelling, hearing, and touching the sickest patients this side of an ICU. I wasn’t so happy about being talked into making a video at the time. Can you tell? She later called me “gracious” for doing so. She has a way of melting everybody like that.

She’s as dedicated to her patients and as impassioned about her mission as a nurse on 3 Boyd Tower as she sounds. I should know. I remember my first days there as a scared stiff subintern. Then I was a scared silly first-year resident. Later when I was what they nowadays call an “early career” assistant professor, I was too dumb to know I should have been scared again.

I’ve always called it the “House of Pain” when greeting a new group of medicine, psychiatry, and pharmacy residents, medical students. I was…not so gray and grumpy once, believe it or not. My wife says I need a little Botox for those twin creases in my brow. I know how I got them. They’re botox-resistant.

I have tried so hard to live up to the ideals of the builder of the House of Pain, Dr. Roger Kathol–who would rather I call it a Complexity Intervention Unit. His eyes are always on the light of what sometimes seems the most remote goal–truly integrated care. I don’t know if I ever saw the light, but I stumbled always in that general direction. I stayed a long time looking for it.

It’s a tough place to work, but it’s the best place for patients with both medical and psychiatric problems. I’ll always believe that. Maritza is right about the family feel to 3BT. How could I not love a place where I was so happy, so sad, angry, enthralled by the light?

Optimistic About Integrated Care

So I’m sitting here looking out at the snow falling outside–in late March. But I’m optimistic because I know spring is just around the corner. That reminds me of an article I recently saw in Clinical Psychiatry News about integrated care [1]. Dr. James Scully, MD, CEO and medical director of the American Psychiatric Association, was interviewed at the meeting of the American College of Psychiatrists in Hawaii. He outlined his impression of what psychiatry has to do to change and what the U.S. payer system has to change about the way it pays for psychiatric services. Fee-for-service has to go in order for patients and doctors to take advantage of the new wave of integrated care service delivery systems that are currently being financed by grants:

North Carolina Center of Excellence in Integrated Care; the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) project; Integrated Behavioral Health Project in California; Improving Mood–Promoting Access to Collaborative Treatment (IMPACT) in Washington State; Mental Health Integration Program, also in Washington State; and TEAMcare, a multidisciplinary collaboration between the University of Washington and the Group Health Research Institute.

Dr. Scully says he’s optimistic about the future of medical and psychiatric care, which he believes will be dominated by integrated care systems. He believes that mental health care providers and insurance carriers will be able to adapt to the era of health care reform being ushered in by the Affordable Care Act. I guess he thinks he’s just a lucky so-and-so…or maybe it’s just that sweet, ionized air blowing in from the Pacific off Kauai.Hawaii birds

Hey, there’s plenty of research evidence showing that integrated care delivery models help get mental health care to primary care patients. All you have to do is look at the bibliography at the Academy of Psychosomatic Medicine website,

We just need a practical way to fund it. Dr. Scully has a dream that’s a pippin and he says we can’t just walk away from health care reform. According to him, “I think we have to participate in this and show some leadership. I’m optimistic.”

I tend to agree. We just have to change the culture of medicine to get the job done. Can we do it? Hey, this is America. We’re just a bunch of  lucky so-and-sos.

1. Brunk, D. Integrative care is the future of psychiatric care Clinical Psychiatry News: News and Views that Matter to Psychiatrists, 2013.