Monday, November 3, 2008

Report from the Field: It is Getting Any Easier?

So, here we are, 10 months into "universal" screening for behavioral health problems, on the cusp of implementing a new and uniform system for evaluation of children who screen positive for mental health services, and a mere 8 months from the promised land of coordinated care, wraparound services and family-centered care.  How does it look from the front-line of the primary care practice?  This week, I came back from vacation to a fairly heavy clinical schedule, and this afforded me, in the dark of the night on Thursday, the opportunity (but not the time) to reflect on that.  Keep in mind that, on top of the screening tests, my practice has recently gone over to an electronic medical record system that I find makes my days in the office quite long (adds about 5% additional time to each encounter, as best we can tell)
Day 1:  It is "winter" now in the office:  many children with colds, coughs, pneumonias, asthma- acute illnesses that we don't see in the spring and summer.  In the summer, about 50% of my patients are scheduled for Well Visits (about 10-14 screens/day);  in the winter, I will typically have about 30% for Well Visits (6-9 screens/day).  On the other hand, it is now two months into the school year, and families are starting to hear about school problems- behavior problems, multiple absences, discipline issues.  A lot of these get raised as what we call "doorknob questions"- a child is brought in for a cough, and, after addressing the cough, and as we are reaching for the doorknob, the parent will say, "By the way, the school asked me to ask you about Joe's attention span."  Also, a lot of my patients on medication for ADHD are coming in for their first quarterly "medication check", another time when concerns are frequently raised.  All of this means that Mental Health issues often present at times when we don't expect them; it is their irregularity that make them tricky.
Monday:  My Well Visits went well;  screens were all negative, and those kids were relatively healthy.  My ADHD rechecks generated a few questions, but none that required a query to MCPAP.   My most complicated questions were from football players- I saw several boys who had suffered concussions or other injuries during play, and who were interesting in returning to play (and whose mother's were interested in their safety).  This involves a bit of psychology, but anxiety is largely parental, and the challenge is adhering to the guidelines that tell us to keep the young men out of play for a while.  I was starting to wonder if Mental Health had magically vanished from my practice.  Turns out that that was not the case.  Left the office at 7 PM- not a bad day.
Tuesday:  Tuesday was a busier day, with a few more kids with overt mental health problems and some with unexplained abdominal pains and headache that may represent mental health problems.  Only 5 physicals, and 5 screens done, none positive.  My challenges came in the physical realm-  a child with pneumonia, some more football injuries and some folks with fevers of questionable origin.  My patients with mental health issues had established diagnoses, and were stable on their medications.  I was a little late out of the office (7:15 AM), but I was starting to think that this was getting easier.
Thursday:  On Thursday, I got to remember why this is still so hard.  I opened with a school age child with some learning issues who may also have ADHD; we've diagnosed him as such, and started treating him with medications a few weeks ago.  It is working, but his family is worried a bit. Are we over-diagnosing him?  Does he need the medication?  Will it help or harm him?  Lots of questions and I hope that I answered them all.  Then I saw brothers, teenagers, one of whom is having a rough time of adolescence.  His PSC was positive, and he clearly identified the things that were bothering him.  I thought that he would be a great candidate for cognitive-behavioral therapy, so I strongly urged him and his parent to get into some therapy.  Will they go?  Did they believe me?  Will he get therapy?  I hope so, and I hope it helps.  But now I am 40 minutes behind schedule (this stuff takes time).  More children with illness, more with mental health issues.  I made it to lunch, only 30 minutes behind and no time for phone calls.  Then the afternoon began, with a young man with bipolar disorder and a series of  complex decisions with which his family is struggling.  Medications, psychiatrists, schools- all hard calls for a school-aged child with  bipolar disorder.  And how sure are we about that diagnosis, if we are not sure what is happening with a child with ADHD?  If my morning conversation made me uncertain, this conversation made me realize in what difficult waters we are treading.  It was a productive visit.   I gave advice, we established some systems for communication and we continued that long walk that begins when you realize that your child is developing down a different path.  And now I am 40 minutes behind.  The day continued- more physicals, but no more positive screens.  More physical illnesses of various kinds.  Many phone calls.  I was 45 minutes behind schedule by the end of the day.  I finished the calls late, and went home to a really late dinner.
Is it getting easier?  Well, the screenings were smooth, but we identified several families today that really needed my help, answering questions, coordinating care, writing prescriptions.  It didn't fit into the day-  our appointments and the frenetic pace of our days really don't make primary care the optimal environment for mental health work.  And yet, I have a relationship with these families, and that relationship is important for them that are undertaking this most important work.  At least, this time, they all had psychiatrists, they had evaluations, they were being treated.  I don't know that it is easier, but it is starting to seem possible.

Everyone go vote, now.  We have much work that needs to be done.

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