A Country Doctor Writes:

One failed and one successful Primary Care/Behavioral Health integration

16 years ago I was a newcomer, at age 56, in the northernmost part of Maine. In one way I was starting over, but in another way, I was continuing what I had done in my previous job near Bangor. There, as medical director, I had a friend and ally in the behavioral health director, and both our departments underwent years of rapid growth. This was in part because we shared patients and patient experiences between our departments and had a bidirectional way of making warm handoffs. If a primary care patient was going through a difficult time with their social life or mental health, we would walk them down the hall to meet a therapist right then and there. Similarly, if a behavioral health patient looked like they had pneumonia, the warm handoff would go in the opposite direction.

The kickoff to my new employer’s effort to integrate primary care and behavioral health led to many more meetings and eventually to embedding one LCSW into each of our relatively small primary care offices. Six years later, about 10 years ago, none of them remained. The organization now employs a single psychiatric nurse practitioner for medication management. No counseling is offered.

My theory is that the behavioral health staff members felt isolated and not integrated with the primary care providers. And I think Bucksport’s success is that there are several behavioral health staff members and a bigger medical staff in the same clinic and they have meetings together, share a lunch room and have easy access to curbside conversations with each other.

The piece quoted below blends the importance of choosing the right, nonjudgmental, words to describe our patients’ symptoms and personalities with the idea that we cannot treat their seemingly physical symptoms without trying to understand the context they arose from.

The Power of Words

Yesterday afternoon I sat in a dark room with a couple of doctors and several mental health professionals and participated in a video conference about integration of primary care and behavioral health. Outside, the late summer sun shone brightly just like it did September 11 eight years ago.

The case for integration is obvious; 85% of the time the ten most common symptoms brought to the attention of primary care doctors (chest pain, dizziness, fatigue, back pain and so on) have no known somatic explanation – the cause for the symptom appears to be psychological.

Yet, the words we use to interview patients, to document the history and physical examination findings, and to present our thoughts to our patients and to our behavioral health consultants are often extremely unhelpful and sometimes downright insulting to the patient.

It seems the place to start integrating primary care and behavioral health is with our everyday choices of words we use to describe the patients we see in our offices.

The days are essentially gone when doctors spoke in technical terms to each other and other medical professionals with the purpose of keeping the patient in the dark. For example, very few of the old prescription-related Latin phrases are still being understood and used by doctors and pharmacists, and most preprinted prescription pads no longer feature the optional “label” box, which in a bygone era gave the prescribing physician the option of not revealing the name of the drug to the patient.

We are nowadays cautioned to clear our vocabulary of words which we as physicians have used and understood to mean something perfectly neutral in clinical language, yet can be offensive to patients, who increasingly often end up reading their own medical records.

In my years as a physician I have read many chart entries that read something like this:

“This pathetic 57 year-old woman returns with a litany of complaints, and seems to completely lack insight into the real cause of her misery…”

Those are words that, perhaps, may insulate a doctor from bad feelings about his/her inability to help such a patient, but they aren’t likely to help the patient manage their symptoms or psychological issues, and they ultimately don’t belong in a therapeutic relationship.

This is not Orwellian Newspeak; our words can heal, and they can hurt. These are some examples of conventional doctorspeak and suggested alternatives from the video presentation we watched by Alexander Blount, Ed. D.:

Chief Complaint = Main Concern

Suffers from = Struggles with

Refused to take = Decided against

Was noncompliant with = Didn’t see the value of

Didn’t keep appointment = Wasn’t able to be here

Arrived late = Was determined not to miss

There is a lot of talk these days in the U.S. about the Patient-Centered Medical Home. It begins here; with the way we see our patients as the center of the clinical work we do, indeed the justification for our own existence as doctors in our communities.

(I see now that I need to write about what happened with the noble idea of a patient centered primary care practice and the stilted, bureaucratic way we had to qualify for certification. Stay tuned for that one…)