Friday, February 29, 2008

An idea for the remedy for Rosie D.: Why wait for the crisis?

Here's an idea on which I need to expand: Primary Mental Health Care (the moral equivalent of Primary Medical Care). It is not how we have set up the system to date, but maybe we need to do so.  Wait- you say- what the heck is this pediatrician talking about?  Let me explain...
  Traditionally, medicine are predicated on an illness model. What do I mean?  Basically, that you are, as a patient, assumed to be healthy most of the time, and, when you are healthy, you don't need the medical care system.  When you are sick (mostly self-defined),  you "access the health care system" (ie go to the doctor/hospital/ER/doc in a box) and get "care" (ie seen/tested/prescribed/surgery).   Our whole system is based on this model- doctors and hospitals are expected to do things to sick people.  In fact, this model is reflected in and reinforced by the economics of medicine;  the more things we do, the more we get paid. Turns out that this is also the easiest kind of medicine to study scientifically- the outcome of "cure"  is much easier to measure than outcome of "health"  Essentially,  we (doctors) are mechanics;  we get paid to fix things that are broken.  If you think about medicine that way, the truism "if it ain't broke, don't fix it" implies that, once the "broken" thing is fixed, we should fade into the woodwork to allow the natural state of "health" to flourish.
  Mental health is set up on the same system.  When we recognize a problem, we send you to a mental health clinician (a counselor or a social worker or a psychologist) for assessment and treatment.  The insurance (public or private) authorizes some period of treatment.  When the "problem" is resolved, the patient is discharged from the system, to re-enter when the problem returns.  
  We began to see the limitations of this model, and created the motion of primary care, initially by pediatricians (the well child conference in the early 20th century) and later in adult medicine.  There is a notion that, if doctors look for the antecedents of illness, we can do a better job of altering the course of illness.  Screening for risk factors (lead levels, anemia, developmental delay, growth abnormalities, cancer, cholesterol, problems in pregnancy) requires us to talk to people BEFORE they have a complaint, which creates a conundrum-  how do you start the conversation?  We create a whole system of annual physicals and periodic exams.  But, as a number of doctors have observed over the years, examination is not enough.  The early signs of disease are most commonly noticed by the person who has the disease, but he or she usually won't discuss these things with a stranger.  To do this kind of care, you need a relationship with your doctor, that has grown trust over time.  The most important part of primary care, it turns out, is the relationship between the the family and doctor.
  Later in the 20th century, we saw the other limitation to the episodic illness model.  Diabetes, asthma, hypertension, cancer, HIV-  these are not actually episodic illnesses.  They don't go away when they are not causig a complaint-  they are lurking below the surface, waiting to resurface.  Over the last quarter century, we have realized that, to treat chronic diseases, we need a chronic disease model.  In this model, we don't just wait for the asthma/ obesity/HIV to show symptoms-  we get together periodically to see how things are going and to tweak our treatment plan.  These "disease management" protocols are sometimes quite complex, and there is a growing suggestion that they are not always best administered by the primary care provider.  In my practice, I do chronic disease management for ADHD and asthma, but not for asthma and cystic fibrosis.  In the case of the latter two conditions, it is really important that both me and the family for which I am caring have an ongoing relationship with a sub-specialty team, skilled and that the relationship goes on when the patient is doing OK AND when the patient is symptomatic.  So what does that mean for the families of children with Serious Emotional Disturbance?
  It is likely that the kids will enter into the category with major symptoms-  suicidal ideation, destructive behaviors, hallucinations.   These kids will be getting lots of care- multiple medications, individual and family therapy, family stabilization.  But what happens when they are stable?  We send them back to the primary care provider, whose relationship with the family is supposed to provide the tripwire for the need for future interventions.  I don't think that this is enough-  these kids shouldn't be limited to visits to the mental health provider for problems, and the mental health providers need to help the families think in terms of mental health care maintenance in addition to treatment.  Families of kids with serious emotional disturbance NEED an ongoing relationship with a mental health care provider IN ADDITION TO an ongoing relationship with a primary care provider.  They need Primary Mental Health Care that is oriented around a model of mental health maintenance, rather than a model of mental health problems.  Truth be told, we could all probably use mental health maintenance.  But the chronic disease model suggests focusing resources on the sickest folks first-  in the world of child mental health, those are the kids with Serious Emotional Disturbance.
  So, how do we build a mental health system that encourages the development of a long term relationship between families and both a mental health professional and a primary care provider?  I think it begins with a recognition that the chronic disease model fits mental health as well as physical health.  That's mental health parity.  We need systems that support mental health professionals to maintain long term practice (burnout avoidance), systems that encourage families to maintain relationship rather than move from crisis to crisis, systems that encourage co-location of primary mental health care and primary health care providers and systems that reward the incorporation of the chronic disease model in to care delivery.  Tall order, isn't it?  We all better get started.
  Long ramble, that one.  Happy Leap Day, y'all.

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