Friday, June 5, 2009

Back in the Field: What Do Primary Care Providers Want?

June in a primary care office is an interesting time;  graduating high school seniors come to see their doctor for the last time before they go to college.   Pre-kindergardeners are looking for their last batch of shots before starting off in school.  This year, we add a bit of the H1N1 swine flu into the mix.  And then, we have the children with behavioral, developmental or psychiatric problems, coming to the doctor for advice on what to do next-  "My med isn't working" or "I changed my mind and want to try medications" or "What do I need to do to see a neuropsychologist?".  The last is a real problem out our way;  the nearest pediatric neuropsychologist is 20 miles away, and appointments are quite difficult.  Yesterday was a slow day:  19 patients (4 "no-shows"), but we had our share of issues.  They raised in my mind some thoughts about the ideal system:
  • A 10 year child with known mental illness, on three meds, currently doing well in school, whose mother is wondering how long to continue this "cocktail" of medication, which were finally finalized in 3 years ago.  "Does he need to stay on the these forever?", she wondered,"When is it safe to change them?"  She finds it hard to discuss these things with psychiatrist in the context of the 15 minute medication check;  she feels guilty that her fabulous child requires this much medication; she feels safer talking about it with me.
But I have no notes from the therapist or psychiatrist on which to base my thoughts, and I have no means of getting my thoughts to the psychiatrist other than through the mother.  Is this the best we can do?
  • A 5 year old child with a normal PEDS but a heaping helpful of energy and a strong desire for attention, who has been adopted by an older couple who sort of understand my reluctance to medicate children before they start kindergarten.  I've tried FST, but the family was unhappy with that in practice.  I will try to refer them to MCPAP, in the hope of getting them hooked up with the CBHI.  
The family is not terribly interested in behavioral approaches or family support;  they want me to use medications in a way in which I am uncomfortable.  Am I wrong to be uncomfortable? Am I hiding behind my algorithms? Or is the system just too darn complicated?

  • An 18 year old overweight boy with autism, on no meds at present, working with his mother to figure out what comes next.  He is pretty well connected with the system, and his mother has opted to give him legal status as an adult.
His life, more or less, is dependent on the votes of the legislature as they realign funds to meet the budget crisis.  How will we arrange his transition of care?

Back in the flow of the community, I perceive that things haven't changed too much.  The CSAs are coming, the system is still complicated and I find that still, the most valuable thing that I can do with patients is to listen.  In June, we sometimes have time to do that.  It is how we learn.

As I was writing this reflection, Matt Noyes of the Children's Mental Health Campaign sent me some things about the Health Plans' testimony at the Mental Health and Substance Abuse Committee hearing last week.  Expect a posting on this soon.

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