Mental Health Consult

Medical students are better prepared for practice when they learn to integrate mental health and team-based care in the academic setting.

“All schools of health professions’ education are moving in that direction,” says Dr. Lawrence “Bopper” Deyton, senior associate dean for public health at George Washington University, Washington. “Nobody has it perfect yet, but I think we’re seeing changes in that direction.”

In this installment of Mental Health Consult, Dr. Deyton and Dr. April Barbour, director of general internal medicine and the primary care residency program at George Washington University, Washington, discuss approaches to teaching integrated mental health care.

Medical students are better prepared for practice when they learn to integrate mental health and team-based care in the academic setting.

“All schools of health professions’ education are moving in that direction,” says Dr. Lawrence “Bopper” Deyton, senior associate dean for public health at George Washington University, Washington. “Nobody has it perfect yet, but I think we’re seeing changes in that direction.”

In this installment of Mental Health Consult, Dr. Deyton and Dr. April Barbour, director of general internal medicine and the primary care residency program at George Washington University, Washington, discuss approaches to teaching integrated mental health care.

Medical students are better prepared for practice when they learn to integrate mental health and team-based care in the academic setting.

“All schools of health professions’ education are moving in that direction,” says Dr. Lawrence “Bopper” Deyton, senior associate dean for public health at George Washington University, Washington. “Nobody has it perfect yet, but I think we’re seeing changes in that direction.”

In this installment of Mental Health Consult, Dr. Deyton and Dr. April Barbour, director of general internal medicine and the primary care residency program at George Washington University, Washington, discuss approaches to teaching integrated mental health care.

Neil Kirschner, Ph.D., senior associate for health policy and regulatory affairs for the American College of Physicians, explains why the solo practitioner model of health care needs to give way to collaborative care. “Care is turning into a team-based approach [that] allows you to have staff to provide effective integration of care, but to have a team, you need funding,” he says. “One-third of our health care spending is on ‘wasted care’ … [and that money] could be leveraged toward providing effective care.” 

Neil Kirschner, Ph.D., senior associate for health policy and regulatory affairs for the American College of Physicians, explains why the solo practitioner model of health care needs to give way to collaborative care. “Care is turning into a team-based approach [that] allows you to have staff to provide effective integration of care, but to have a team, you need funding,” he says. “One-third of our health care spending is on ‘wasted care’ … [and that money] could be leveraged toward providing effective care.” 

Neil Kirschner, Ph.D., senior associate for health policy and regulatory affairs for the American College of Physicians, explains why the solo practitioner model of health care needs to give way to collaborative care. “Care is turning into a team-based approach [that] allows you to have staff to provide effective integration of care, but to have a team, you need funding,” he says. “One-third of our health care spending is on ‘wasted care’ … [and that money] could be leveraged toward providing effective care.” 

Who is in this video: Neil Kirschner, Ph.D., a clinical psychologist and the American College of Physicians’ senior associate for health policy and regulatory affairs; Dr. April Barbour, an associate professor of medicine and the director of general internal medicine and of the primary care residency program at George Washington University School of Medicine, Washington; Dr. James Griffith, the Leon M. Yochelson Professor of Psychiatry and Behavioral Sciences, and chair of psychiatry and psychosomatic medicine at George Washington University School of Medicine, Washington; Whitney McKnight, cohost and producer of Mental Health Consult.

Who is in this video: Neil Kirschner, Ph.D., a clinical psychologist and the American College of Physicians’ senior associate for health policy and regulatory affairs; Dr. April Barbour, an associate professor of medicine and the director of general internal medicine and of the primary care residency program at George Washington University School of Medicine, Washington; Dr. James Griffith, the Leon M. Yochelson Professor of Psychiatry and Behavioral Sciences, and chair of psychiatry and psychosomatic medicine at George Washington University School of Medicine, Washington; Whitney McKnight, cohost and producer of Mental Health Consult.

Who is in this video: Neil Kirschner, Ph.D., a clinical psychologist and the American College of Physicians’ senior associate for health policy and regulatory affairs; Dr. April Barbour, an associate professor of medicine and the director of general internal medicine and of the primary care residency program at George Washington University School of Medicine, Washington; Dr. James Griffith, the Leon M. Yochelson Professor of Psychiatry and Behavioral Sciences, and chair of psychiatry and psychosomatic medicine at George Washington University School of Medicine, Washington; Whitney McKnight, cohost and producer of Mental Health Consult.

People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, editorial board member of Clinical Psychiatry News and cohost of Mental Health Consult, and an assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs, and the medical director of psychiatric and behavioral services at George Washington University Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington, and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine in Baltimore and at the Uniformed Services University of the Health Sciences in Bethesda, Md.

Dr. Pickar: Psychosis is the hallmark of serious mental illness, whether it's schizophrenia, severe bipolar, or psychosis otherwise. It is one of the great tragedies of our medical system, and I'll come back to the primary doc who's out there. I want to talk to you about this. It is a tragedy. Whitney knows, I put together a little documentary, The Realities of Serious Mental Illness. I just couldn't stand the lack of information.

They're very quick to report the violence, and I know a lot about the violence. I worry about it all the time. There's a huge debate between civil liberties and safety that's going on in serious mental illness. Regardless, knowing about it is enormously important for all docs. More patients with serious mental illness, by far, are in jails than they are in mental hospitals. There is nothing for them. You talk about collaborative care.
 
Whitney: On the team in the primary care setting, who's treating what?

Dr. Pickar: I'm talking now myself. A family member brings in an 18-year-old to evaluate. Okay? I'm glad to see it. Of course, I've been around a while. I spent decades as a scientist in schizophrenia. I just close my eyes and hope that I'm not seeing a first break for a seriously mental ill patient. Not that we can't treat it. Not that we can't help, but I know what's entailed. Not unlike seeing an oncology presentation. We're there. We're docs. You don't give up on it, but you know what's ahead for that family.

What's fascinating is many of the first breaks occur, not necessarily quietly, but can be a little insidious. They can be brought to the primary care. It is not uncommon. “My 16-year-old's not doing well. I can't get him up.” But really, what's going on? The primary care doc needs to have a consciousness of that. Let me just say this: First things about serious mental illness, particularly in schizophrenia, 1% of the population has it. That makes it a very common disorder.

People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, editorial board member of Clinical Psychiatry News and cohost of Mental Health Consult, and an assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs, and the medical director of psychiatric and behavioral services at George Washington University Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington, and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine in Baltimore and at the Uniformed Services University of the Health Sciences in Bethesda, Md.

Dr. Pickar: Psychosis is the hallmark of serious mental illness, whether it's schizophrenia, severe bipolar, or psychosis otherwise. It is one of the great tragedies of our medical system, and I'll come back to the primary doc who's out there. I want to talk to you about this. It is a tragedy. Whitney knows, I put together a little documentary, The Realities of Serious Mental Illness. I just couldn't stand the lack of information.

They're very quick to report the violence, and I know a lot about the violence. I worry about it all the time. There's a huge debate between civil liberties and safety that's going on in serious mental illness. Regardless, knowing about it is enormously important for all docs. More patients with serious mental illness, by far, are in jails than they are in mental hospitals. There is nothing for them. You talk about collaborative care.
 
Whitney: On the team in the primary care setting, who's treating what?

Dr. Pickar: I'm talking now myself. A family member brings in an 18-year-old to evaluate. Okay? I'm glad to see it. Of course, I've been around a while. I spent decades as a scientist in schizophrenia. I just close my eyes and hope that I'm not seeing a first break for a seriously mental ill patient. Not that we can't treat it. Not that we can't help, but I know what's entailed. Not unlike seeing an oncology presentation. We're there. We're docs. You don't give up on it, but you know what's ahead for that family.

What's fascinating is many of the first breaks occur, not necessarily quietly, but can be a little insidious. They can be brought to the primary care. It is not uncommon. “My 16-year-old's not doing well. I can't get him up.” But really, what's going on? The primary care doc needs to have a consciousness of that. Let me just say this: First things about serious mental illness, particularly in schizophrenia, 1% of the population has it. That makes it a very common disorder.

People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, editorial board member of Clinical Psychiatry News and cohost of Mental Health Consult, and an assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs, and the medical director of psychiatric and behavioral services at George Washington University Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington, and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine in Baltimore and at the Uniformed Services University of the Health Sciences in Bethesda, Md.

Dr. Pickar: Psychosis is the hallmark of serious mental illness, whether it's schizophrenia, severe bipolar, or psychosis otherwise. It is one of the great tragedies of our medical system, and I'll come back to the primary doc who's out there. I want to talk to you about this. It is a tragedy. Whitney knows, I put together a little documentary, The Realities of Serious Mental Illness. I just couldn't stand the lack of information.

They're very quick to report the violence, and I know a lot about the violence. I worry about it all the time. There's a huge debate between civil liberties and safety that's going on in serious mental illness. Regardless, knowing about it is enormously important for all docs. More patients with serious mental illness, by far, are in jails than they are in mental hospitals. There is nothing for them. You talk about collaborative care.
 
Whitney: On the team in the primary care setting, who's treating what?

Dr. Pickar: I'm talking now myself. A family member brings in an 18-year-old to evaluate. Okay? I'm glad to see it. Of course, I've been around a while. I spent decades as a scientist in schizophrenia. I just close my eyes and hope that I'm not seeing a first break for a seriously mental ill patient. Not that we can't treat it. Not that we can't help, but I know what's entailed. Not unlike seeing an oncology presentation. We're there. We're docs. You don't give up on it, but you know what's ahead for that family.

What's fascinating is many of the first breaks occur, not necessarily quietly, but can be a little insidious. They can be brought to the primary care. It is not uncommon. “My 16-year-old's not doing well. I can't get him up.” But really, what's going on? The primary care doc needs to have a consciousness of that. Let me just say this: First things about serious mental illness, particularly in schizophrenia, 1% of the population has it. That makes it a very common disorder.

Who is in this video: Dr. Lawrence “Bopper” Deyton is the senior associate dean for clinical public health and a professor of medicine and of health policy and management at George Washington University School of Medicine, Washington; and Lauren Alfred, policy director at the Kennedy Forum.

Dr. Deyton: We’re in a bit of a transition now in terms of the structure of the health care enterprise, and how the incentives, and the funding, and how we’re organized? If we believe that the “triple aim” will work, that is, that the Affordable Care Act’s priorities – improving quality, decreasing cost, improving patient satisfaction in the system – then aren’t we on the cusp of potentially being able to put the distress diagnoses, finding those out, at the top, or close to the top, of the differential list when anybody comes in for any medical interaction?

At least in the literature that I know about – I’m thinking about chronic diseases – people come in with all kinds of behavioral, and emotional, and mental health distress issues, as well as serious mental illness. I think that we are missing opportunities with every interaction to ask about, to screen, and to have a treatment plan for those behavioral and mental health problems.
 
Now, aren’t we at the cusp of a reimbursement system that should reward for that and help catalyze our systems to change how they are structured?

Lauren Alfred: Absolutely. I think we’re having this conversation, fundamentally, for two reasons. One, because we recognize that the vast majority of patients are going to get this care in the primary care setting. That’s why we’re talking about mental health in primary care. There’s recognition of that by policy makers to say, “I have to address this problem across the continuum of care, but this is where I can make the biggest impact.” They’re driven by dollars, and so this is Then two, back to the idea of education, and the burden that we would be placing on primary care physicians and on our residents to be learning, there is only so much we can do, I would say, given the evidence of education in mental health for these physicians. It’ll only take them so far, and then at some point we have to talk about collaborative care and where we’re going to bring the specialists into the equation.

I think we get into this policy discussion, certainly with medicine, but also with teachers. It’s “How much more are we going to pile onto educators in terms of the things that they have to do for their students?” They have to be the social worker, the mom, the dad, and they have to be thinking about their mental health and about addiction. There are only so many [14:50] things we can expect our primary care physicians to do.

We need to bring them all up to a certain standard and at that point decide, “What are the payment structures, mechanisms, and teams that are in place that then carry us the rest of the way?” Making sure that there is a fundamental understanding of this difference between disorder and distress is certainly a good place to start.
 

Who is in this video: Dr. Lawrence “Bopper” Deyton is the senior associate dean for clinical public health and a professor of medicine and of health policy and management at George Washington University School of Medicine, Washington; and Lauren Alfred, policy director at the Kennedy Forum.

Dr. Deyton: We’re in a bit of a transition now in terms of the structure of the health care enterprise, and how the incentives, and the funding, and how we’re organized? If we believe that the “triple aim” will work, that is, that the Affordable Care Act’s priorities – improving quality, decreasing cost, improving patient satisfaction in the system – then aren’t we on the cusp of potentially being able to put the distress diagnoses, finding those out, at the top, or close to the top, of the differential list when anybody comes in for any medical interaction?

At least in the literature that I know about – I’m thinking about chronic diseases – people come in with all kinds of behavioral, and emotional, and mental health distress issues, as well as serious mental illness. I think that we are missing opportunities with every interaction to ask about, to screen, and to have a treatment plan for those behavioral and mental health problems.
 
Now, aren’t we at the cusp of a reimbursement system that should reward for that and help catalyze our systems to change how they are structured?

Lauren Alfred: Absolutely. I think we’re having this conversation, fundamentally, for two reasons. One, because we recognize that the vast majority of patients are going to get this care in the primary care setting. That’s why we’re talking about mental health in primary care. There’s recognition of that by policy makers to say, “I have to address this problem across the continuum of care, but this is where I can make the biggest impact.” They’re driven by dollars, and so this is Then two, back to the idea of education, and the burden that we would be placing on primary care physicians and on our residents to be learning, there is only so much we can do, I would say, given the evidence of education in mental health for these physicians. It’ll only take them so far, and then at some point we have to talk about collaborative care and where we’re going to bring the specialists into the equation.

I think we get into this policy discussion, certainly with medicine, but also with teachers. It’s “How much more are we going to pile onto educators in terms of the things that they have to do for their students?” They have to be the social worker, the mom, the dad, and they have to be thinking about their mental health and about addiction. There are only so many [14:50] things we can expect our primary care physicians to do.

We need to bring them all up to a certain standard and at that point decide, “What are the payment structures, mechanisms, and teams that are in place that then carry us the rest of the way?” Making sure that there is a fundamental understanding of this difference between disorder and distress is certainly a good place to start.
 

Who is in this video: Dr. Lawrence “Bopper” Deyton is the senior associate dean for clinical public health and a professor of medicine and of health policy and management at George Washington University School of Medicine, Washington; and Lauren Alfred, policy director at the Kennedy Forum.

Dr. Deyton: We’re in a bit of a transition now in terms of the structure of the health care enterprise, and how the incentives, and the funding, and how we’re organized? If we believe that the “triple aim” will work, that is, that the Affordable Care Act’s priorities – improving quality, decreasing cost, improving patient satisfaction in the system – then aren’t we on the cusp of potentially being able to put the distress diagnoses, finding those out, at the top, or close to the top, of the differential list when anybody comes in for any medical interaction?

At least in the literature that I know about – I’m thinking about chronic diseases – people come in with all kinds of behavioral, and emotional, and mental health distress issues, as well as serious mental illness. I think that we are missing opportunities with every interaction to ask about, to screen, and to have a treatment plan for those behavioral and mental health problems.
 
Now, aren’t we at the cusp of a reimbursement system that should reward for that and help catalyze our systems to change how they are structured?

Lauren Alfred: Absolutely. I think we’re having this conversation, fundamentally, for two reasons. One, because we recognize that the vast majority of patients are going to get this care in the primary care setting. That’s why we’re talking about mental health in primary care. There’s recognition of that by policy makers to say, “I have to address this problem across the continuum of care, but this is where I can make the biggest impact.” They’re driven by dollars, and so this is Then two, back to the idea of education, and the burden that we would be placing on primary care physicians and on our residents to be learning, there is only so much we can do, I would say, given the evidence of education in mental health for these physicians. It’ll only take them so far, and then at some point we have to talk about collaborative care and where we’re going to bring the specialists into the equation.

I think we get into this policy discussion, certainly with medicine, but also with teachers. It’s “How much more are we going to pile onto educators in terms of the things that they have to do for their students?” They have to be the social worker, the mom, the dad, and they have to be thinking about their mental health and about addiction. There are only so many [14:50] things we can expect our primary care physicians to do.

We need to bring them all up to a certain standard and at that point decide, “What are the payment structures, mechanisms, and teams that are in place that then carry us the rest of the way?” Making sure that there is a fundamental understanding of this difference between disorder and distress is certainly a good place to start.
 

People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, editorial board member of Clinical Psychiatry News and cohost of Mental Health Consult, and an assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs, and the medical director of psychiatric and behavioral services at George Washington University Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington, and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine in Baltimore  and at the Uniformed Services University of the Health Sciences in Bethesda, Md.

Dr. Lillian Beard: In fact, the written note is sometimes inhibiting to the communication because we are each so aware of what we put in writing [20:00] to even send to a colleague. We can have a conversation, a dialogue about the patient and glean a lot more information.

Whitney: Do you mean you actually omit things on purpose?

Dr. Beard: It is not about omitting, it is about how you state it, because first of all our patients will eventually have access to everything we have written. They are getting more and more access with patient portals. I find for instance even in my notes, so that even if my colleagues in my practice were to see this patient they would know there are certain code terms. I say "high risk for" or I will not do that now because much of that will go to the patient portal. I will come up with other kinds of words so they know to check with me to find out what I meant about that. There are some toxic families, I do not write "toxic family" in my notes.

Dr. Pickar: I agree with you. I could not agree with you more, and in psychiatry, actually there is some protection against not having to share notes. I do not know if you are aware of that. Medical records for sure, but your notes can remain private about a patient. Maybe you know more about that. Help me with that.

Dr. Norris: It is a little bit. Once you get into the problem of keeping dual records, which becomes an issue. You cannot do that. Particularly with electronic medical records, this is now one that patients do and should have access to it. It is a medical legal document and many different people can look at that, so as clinicians, we must be aware, not just for our patients and ourselves, what we put in the note. You cannot have team-based care unless you actually know your teammate. When I am working with a clinician, I want to know their thought process. I want to know a little bit of their philosophy. Do they like stimulants, do they believe in them? When they are also treating, do they screen for first-episode psychosis? Is it on their radar? Are they screening for comorbid depression and bipolar disorder?

Whitney: Should that be legislated or should that be the individual choice of the practice?

Dr. Norris: You can legislate it all you want. This gets into the duty that we as clinicians have to our patients and how we treat them. The first law is to do no harm. I am not saying anything fancy. This is just basic, solid medical care, which takes a certain amount of time, which is not usually 15 minutes.
 

People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, editorial board member of Clinical Psychiatry News and cohost of Mental Health Consult, and an assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs, and the medical director of psychiatric and behavioral services at George Washington University Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington, and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine in Baltimore  and at the Uniformed Services University of the Health Sciences in Bethesda, Md.

Dr. Lillian Beard: In fact, the written note is sometimes inhibiting to the communication because we are each so aware of what we put in writing [20:00] to even send to a colleague. We can have a conversation, a dialogue about the patient and glean a lot more information.

Whitney: Do you mean you actually omit things on purpose?

Dr. Beard: It is not about omitting, it is about how you state it, because first of all our patients will eventually have access to everything we have written. They are getting more and more access with patient portals. I find for instance even in my notes, so that even if my colleagues in my practice were to see this patient they would know there are certain code terms. I say "high risk for" or I will not do that now because much of that will go to the patient portal. I will come up with other kinds of words so they know to check with me to find out what I meant about that. There are some toxic families, I do not write "toxic family" in my notes.

Dr. Pickar: I agree with you. I could not agree with you more, and in psychiatry, actually there is some protection against not having to share notes. I do not know if you are aware of that. Medical records for sure, but your notes can remain private about a patient. Maybe you know more about that. Help me with that.

Dr. Norris: It is a little bit. Once you get into the problem of keeping dual records, which becomes an issue. You cannot do that. Particularly with electronic medical records, this is now one that patients do and should have access to it. It is a medical legal document and many different people can look at that, so as clinicians, we must be aware, not just for our patients and ourselves, what we put in the note. You cannot have team-based care unless you actually know your teammate. When I am working with a clinician, I want to know their thought process. I want to know a little bit of their philosophy. Do they like stimulants, do they believe in them? When they are also treating, do they screen for first-episode psychosis? Is it on their radar? Are they screening for comorbid depression and bipolar disorder?

Whitney: Should that be legislated or should that be the individual choice of the practice?

Dr. Norris: You can legislate it all you want. This gets into the duty that we as clinicians have to our patients and how we treat them. The first law is to do no harm. I am not saying anything fancy. This is just basic, solid medical care, which takes a certain amount of time, which is not usually 15 minutes.
 

People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, editorial board member of Clinical Psychiatry News and cohost of Mental Health Consult, and an assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs, and the medical director of psychiatric and behavioral services at George Washington University Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington, and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine in Baltimore  and at the Uniformed Services University of the Health Sciences in Bethesda, Md.

Dr. Lillian Beard: In fact, the written note is sometimes inhibiting to the communication because we are each so aware of what we put in writing [20:00] to even send to a colleague. We can have a conversation, a dialogue about the patient and glean a lot more information.

Whitney: Do you mean you actually omit things on purpose?

Dr. Beard: It is not about omitting, it is about how you state it, because first of all our patients will eventually have access to everything we have written. They are getting more and more access with patient portals. I find for instance even in my notes, so that even if my colleagues in my practice were to see this patient they would know there are certain code terms. I say "high risk for" or I will not do that now because much of that will go to the patient portal. I will come up with other kinds of words so they know to check with me to find out what I meant about that. There are some toxic families, I do not write "toxic family" in my notes.

Dr. Pickar: I agree with you. I could not agree with you more, and in psychiatry, actually there is some protection against not having to share notes. I do not know if you are aware of that. Medical records for sure, but your notes can remain private about a patient. Maybe you know more about that. Help me with that.

Dr. Norris: It is a little bit. Once you get into the problem of keeping dual records, which becomes an issue. You cannot do that. Particularly with electronic medical records, this is now one that patients do and should have access to it. It is a medical legal document and many different people can look at that, so as clinicians, we must be aware, not just for our patients and ourselves, what we put in the note. You cannot have team-based care unless you actually know your teammate. When I am working with a clinician, I want to know their thought process. I want to know a little bit of their philosophy. Do they like stimulants, do they believe in them? When they are also treating, do they screen for first-episode psychosis? Is it on their radar? Are they screening for comorbid depression and bipolar disorder?

Whitney: Should that be legislated or should that be the individual choice of the practice?

Dr. Norris: You can legislate it all you want. This gets into the duty that we as clinicians have to our patients and how we treat them. The first law is to do no harm. I am not saying anything fancy. This is just basic, solid medical care, which takes a certain amount of time, which is not usually 15 minutes.
 

Who is in this video: Dr. James Griffith, the Leon M. Yochelson Professor of Psychiatry and Behavioral Sciences, and chair of psychiatry and psychosomatic medicine at George Washington University School of Medicine. Lauren Alfred is policy director at the Kennedy Forum.

Dr. Griffith: There’s also the training of our educators. There has been too much focus simply on counting symptoms. If you have sleep problems, if you have no energy, if you’re not enjoying things, then you have depression. That kind of definition of depression catches too many different things that shouldn’t be addressed in the same way.

“There has been too much focus simply on counting symptoms.”
– Dr. James GriffithThat’s distress. In primary care there are a lot of people with, often, very malignant mood disorders – major depression, bipolar disorder. They generally need not just a prescription; they need a program. Medication may be part of it. It also needs to address lifestyle. It also needs to address relationship problems. Many different things, which if done well can help people live good lives without being held hostage to having a psychiatric diagnosis.

When I said distress – these are not mental illnesses, but yet it all gets called depression. Often in the public discussions, it’s treated – “We just need to identify the depressed patients, give them medications.” That serves few people well. There are ways of doing very effective, targeted work depending upon, initially, an accurate assessment of what is the problem. Is it demoralization? Is it grief? Is this a relationship that is abusive, for example?

Now the other piece - and this is a big one. This is one that we’ve got to figure out how to address, and this is no different in the Middle East, where I’m doing work, as it is here. People come into primary care complaining of dizziness, headaches, physical pain problems, not sleeping well, fatigue. Wherever in the world you’ll go, what they get is a lot of tests, vitamins – not identifying or addressing that underneath this there is psychological distress or a mental illness driving it.

This puts a focus on detection and formulation of the problem. You’re right, the doctors aren’t going to do all the treatment, but this is where the doctor pretty much does have to do, on the front end, the identification. That’s our training issue.
 

Who is in this video: Dr. James Griffith, the Leon M. Yochelson Professor of Psychiatry and Behavioral Sciences, and chair of psychiatry and psychosomatic medicine at George Washington University School of Medicine. Lauren Alfred is policy director at the Kennedy Forum.

Dr. Griffith: There’s also the training of our educators. There has been too much focus simply on counting symptoms. If you have sleep problems, if you have no energy, if you’re not enjoying things, then you have depression. That kind of definition of depression catches too many different things that shouldn’t be addressed in the same way.

“There has been too much focus simply on counting symptoms.”
– Dr. James GriffithThat’s distress. In primary care there are a lot of people with, often, very malignant mood disorders – major depression, bipolar disorder. They generally need not just a prescription; they need a program. Medication may be part of it. It also needs to address lifestyle. It also needs to address relationship problems. Many different things, which if done well can help people live good lives without being held hostage to having a psychiatric diagnosis.

When I said distress – these are not mental illnesses, but yet it all gets called depression. Often in the public discussions, it’s treated – “We just need to identify the depressed patients, give them medications.” That serves few people well. There are ways of doing very effective, targeted work depending upon, initially, an accurate assessment of what is the problem. Is it demoralization? Is it grief? Is this a relationship that is abusive, for example?

Now the other piece - and this is a big one. This is one that we’ve got to figure out how to address, and this is no different in the Middle East, where I’m doing work, as it is here. People come into primary care complaining of dizziness, headaches, physical pain problems, not sleeping well, fatigue. Wherever in the world you’ll go, what they get is a lot of tests, vitamins – not identifying or addressing that underneath this there is psychological distress or a mental illness driving it.

This puts a focus on detection and formulation of the problem. You’re right, the doctors aren’t going to do all the treatment, but this is where the doctor pretty much does have to do, on the front end, the identification. That’s our training issue.
 

Who is in this video: Dr. James Griffith, the Leon M. Yochelson Professor of Psychiatry and Behavioral Sciences, and chair of psychiatry and psychosomatic medicine at George Washington University School of Medicine. Lauren Alfred is policy director at the Kennedy Forum.

Dr. Griffith: There’s also the training of our educators. There has been too much focus simply on counting symptoms. If you have sleep problems, if you have no energy, if you’re not enjoying things, then you have depression. That kind of definition of depression catches too many different things that shouldn’t be addressed in the same way.

“There has been too much focus simply on counting symptoms.”
– Dr. James GriffithThat’s distress. In primary care there are a lot of people with, often, very malignant mood disorders – major depression, bipolar disorder. They generally need not just a prescription; they need a program. Medication may be part of it. It also needs to address lifestyle. It also needs to address relationship problems. Many different things, which if done well can help people live good lives without being held hostage to having a psychiatric diagnosis.

When I said distress – these are not mental illnesses, but yet it all gets called depression. Often in the public discussions, it’s treated – “We just need to identify the depressed patients, give them medications.” That serves few people well. There are ways of doing very effective, targeted work depending upon, initially, an accurate assessment of what is the problem. Is it demoralization? Is it grief? Is this a relationship that is abusive, for example?

Now the other piece - and this is a big one. This is one that we’ve got to figure out how to address, and this is no different in the Middle East, where I’m doing work, as it is here. People come into primary care complaining of dizziness, headaches, physical pain problems, not sleeping well, fatigue. Wherever in the world you’ll go, what they get is a lot of tests, vitamins – not identifying or addressing that underneath this there is psychological distress or a mental illness driving it.

This puts a focus on detection and formulation of the problem. You’re right, the doctors aren’t going to do all the treatment, but this is where the doctor pretty much does have to do, on the front end, the identification. That’s our training issue.
 

People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, an editorial board member for Clinical Psychiatry News, and assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs at G.W. University School of Medicine & Health Sciences, and the medical director of psychiatric and behavioral services at G.W.U. Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington,  and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine in Baltimore and at the Uniformed Services University of the Health Sciences in Bethesda, Md.

Dr. Pickar: Let me just say one thing about that training issue and so forth. There is a common ground in primary care medicine and psychiatry and that is the patient. You guys in primary care, you know patients. We do not use – I use stethoscopes – to make me feel like an internist again.

However, we psychiatrists really do not have to.

Whitney: Is that like “I’m not a doctor but I play one on TV”?

Dr. Pickar: I do that one, too, but in fact the real first step of evidence-based medicine is the patient. You just described it beautifully. Sometimes, I feel badly if the primary physician does not give him or herself credit for that first line of clinical observation. It is huge. Affect is the feeling state. You observe the affect: “He looks down or agitated, anxious.” That is affect, whereas the symptoms are if he is feeling sad, feeling anxious. That is what you do for a living, you find out these things. You get that piece going. We know we psychiatrists are going to need help in that direction. The issue around reimbursement for psychiatry and so forth, I am going to take a deep breath on that one.

I have plenty of feelings about that, but I just want to make sure that the primary care physician that may be watching this understands that he or she is not just the first line but he or she has good skills at observing the first pass what is going on with a patient.

Dr. Norris: Not only are they the first line, but frequently, if you are the person the patient has the relationship with – Dr. Beard, Dr. Barbour – the patient is more inclined to listen to you than to just some random specialist you refer them to.

Dr. Pickar: On the other side of that, even when you have collaborated with a primary care doctor, and times are changing and the meds are tricky, I like to be able to talk to the primary care person and say “Look, I am thinking this way …” The primary doctor might say, “I saw them and they were not looking bad,” that is helpful to hear, or “Yeah, boy we need to ...” That is helpful.

Dr. Norris: Not just a digital note on a shared electronic medical records. Talk … dialogue. There is a difference. This is an important point, there is a difference between clinicians dialogue on a shared patient versus I am reading your notes and you are reading my notes. I do not consider that dialogue.
 

People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, an editorial board member for Clinical Psychiatry News, and assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs at G.W. University School of Medicine & Health Sciences, and the medical director of psychiatric and behavioral services at G.W.U. Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington,  and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine in Baltimore and at the Uniformed Services University of the Health Sciences in Bethesda, Md.

Dr. Pickar: Let me just say one thing about that training issue and so forth. There is a common ground in primary care medicine and psychiatry and that is the patient. You guys in primary care, you know patients. We do not use – I use stethoscopes – to make me feel like an internist again.

However, we psychiatrists really do not have to.

Whitney: Is that like “I’m not a doctor but I play one on TV”?

Dr. Pickar: I do that one, too, but in fact the real first step of evidence-based medicine is the patient. You just described it beautifully. Sometimes, I feel badly if the primary physician does not give him or herself credit for that first line of clinical observation. It is huge. Affect is the feeling state. You observe the affect: “He looks down or agitated, anxious.” That is affect, whereas the symptoms are if he is feeling sad, feeling anxious. That is what you do for a living, you find out these things. You get that piece going. We know we psychiatrists are going to need help in that direction. The issue around reimbursement for psychiatry and so forth, I am going to take a deep breath on that one.

I have plenty of feelings about that, but I just want to make sure that the primary care physician that may be watching this understands that he or she is not just the first line but he or she has good skills at observing the first pass what is going on with a patient.

Dr. Norris: Not only are they the first line, but frequently, if you are the person the patient has the relationship with – Dr. Beard, Dr. Barbour – the patient is more inclined to listen to you than to just some random specialist you refer them to.

Dr. Pickar: On the other side of that, even when you have collaborated with a primary care doctor, and times are changing and the meds are tricky, I like to be able to talk to the primary care person and say “Look, I am thinking this way …” The primary doctor might say, “I saw them and they were not looking bad,” that is helpful to hear, or “Yeah, boy we need to ...” That is helpful.

Dr. Norris: Not just a digital note on a shared electronic medical records. Talk … dialogue. There is a difference. This is an important point, there is a difference between clinicians dialogue on a shared patient versus I am reading your notes and you are reading my notes. I do not consider that dialogue.
 

People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, an editorial board member for Clinical Psychiatry News, and assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs at G.W. University School of Medicine & Health Sciences, and the medical director of psychiatric and behavioral services at G.W.U. Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington,  and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine in Baltimore and at the Uniformed Services University of the Health Sciences in Bethesda, Md.

Dr. Pickar: Let me just say one thing about that training issue and so forth. There is a common ground in primary care medicine and psychiatry and that is the patient. You guys in primary care, you know patients. We do not use – I use stethoscopes – to make me feel like an internist again.

However, we psychiatrists really do not have to.

Whitney: Is that like “I’m not a doctor but I play one on TV”?

Dr. Pickar: I do that one, too, but in fact the real first step of evidence-based medicine is the patient. You just described it beautifully. Sometimes, I feel badly if the primary physician does not give him or herself credit for that first line of clinical observation. It is huge. Affect is the feeling state. You observe the affect: “He looks down or agitated, anxious.” That is affect, whereas the symptoms are if he is feeling sad, feeling anxious. That is what you do for a living, you find out these things. You get that piece going. We know we psychiatrists are going to need help in that direction. The issue around reimbursement for psychiatry and so forth, I am going to take a deep breath on that one.

I have plenty of feelings about that, but I just want to make sure that the primary care physician that may be watching this understands that he or she is not just the first line but he or she has good skills at observing the first pass what is going on with a patient.

Dr. Norris: Not only are they the first line, but frequently, if you are the person the patient has the relationship with – Dr. Beard, Dr. Barbour – the patient is more inclined to listen to you than to just some random specialist you refer them to.

Dr. Pickar: On the other side of that, even when you have collaborated with a primary care doctor, and times are changing and the meds are tricky, I like to be able to talk to the primary care person and say “Look, I am thinking this way …” The primary doctor might say, “I saw them and they were not looking bad,” that is helpful to hear, or “Yeah, boy we need to ...” That is helpful.

Dr. Norris: Not just a digital note on a shared electronic medical records. Talk … dialogue. There is a difference. This is an important point, there is a difference between clinicians dialogue on a shared patient versus I am reading your notes and you are reading my notes. I do not consider that dialogue.
 

People in this video: Dr. James Griffith, the Leon M. Yochelson Professor of Psychiatry and Behavioral Sciences, and chair of psychiatry and psychosomatic medicine at George Washington University School of Medicine, Washington; Whitney McKnight, cohost and producer of Mental Health Consult.

Whitney: I think we need to step back and define mental illness. For that, I’m going to go to you, Griff, because I think it’s important that we remember not all primary care doctors really do have an understanding of the nuances to definitions of mental health.

You and I were having a discussion about “How do you define depression?” There’s clinical diagnosis of it, but then there are other ways that it gets used.

Dr. James Griffith: There’s a big push in medical education to shorten it, to do more in less time, but this is complex. There has not been much acknowledgment of the complexity. I’ll give you two difficult scenarios.

“Huge numbers of people treated in primary care who would have high scores on the PHQ-9 are in fact just lonely.” – Dr. James GriffithOne is disorder versus distress. If you simply download a Patient Health Questionnaire-9 off the Internet, give it to people: They have a high score; we say they’re depressed, give them an antidepressant. Huge numbers of people in primary care who would have high depression scores, in fact, are lonely; they’re in abusive relationships; they’re grieving losses; they are demoralized because their aspirations in life won’t take place – none of these problems are helped by an antidepressant.

Medical students, or for that matter, psychiatry residents, are not well taught in how to distinguish disorder from distress. All of these are solvable problems. There’s sort of a myth of the depressed patient that if only we would recognize depressed people, give them a prescription, everything would be okay, but it doesn’t.

Whitney: How do you teach that, then? What is missing in the curriculum?

Dr. Griffith: It’s a little bit like what Dr. Kirschner said about money and teams. You don’t have teams, if you don’t have funding. You don’t have teaching, if you don’t have time, and that’s one of our first issues.

People in this video: Dr. James Griffith, the Leon M. Yochelson Professor of Psychiatry and Behavioral Sciences, and chair of psychiatry and psychosomatic medicine at George Washington University School of Medicine, Washington; Whitney McKnight, cohost and producer of Mental Health Consult.

Whitney: I think we need to step back and define mental illness. For that, I’m going to go to you, Griff, because I think it’s important that we remember not all primary care doctors really do have an understanding of the nuances to definitions of mental health.

You and I were having a discussion about “How do you define depression?” There’s clinical diagnosis of it, but then there are other ways that it gets used.

Dr. James Griffith: There’s a big push in medical education to shorten it, to do more in less time, but this is complex. There has not been much acknowledgment of the complexity. I’ll give you two difficult scenarios.

“Huge numbers of people treated in primary care who would have high scores on the PHQ-9 are in fact just lonely.” – Dr. James GriffithOne is disorder versus distress. If you simply download a Patient Health Questionnaire-9 off the Internet, give it to people: They have a high score; we say they’re depressed, give them an antidepressant. Huge numbers of people in primary care who would have high depression scores, in fact, are lonely; they’re in abusive relationships; they’re grieving losses; they are demoralized because their aspirations in life won’t take place – none of these problems are helped by an antidepressant.

Medical students, or for that matter, psychiatry residents, are not well taught in how to distinguish disorder from distress. All of these are solvable problems. There’s sort of a myth of the depressed patient that if only we would recognize depressed people, give them a prescription, everything would be okay, but it doesn’t.

Whitney: How do you teach that, then? What is missing in the curriculum?

Dr. Griffith: It’s a little bit like what Dr. Kirschner said about money and teams. You don’t have teams, if you don’t have funding. You don’t have teaching, if you don’t have time, and that’s one of our first issues.

People in this video: Dr. James Griffith, the Leon M. Yochelson Professor of Psychiatry and Behavioral Sciences, and chair of psychiatry and psychosomatic medicine at George Washington University School of Medicine, Washington; Whitney McKnight, cohost and producer of Mental Health Consult.

Whitney: I think we need to step back and define mental illness. For that, I’m going to go to you, Griff, because I think it’s important that we remember not all primary care doctors really do have an understanding of the nuances to definitions of mental health.

You and I were having a discussion about “How do you define depression?” There’s clinical diagnosis of it, but then there are other ways that it gets used.

Dr. James Griffith: There’s a big push in medical education to shorten it, to do more in less time, but this is complex. There has not been much acknowledgment of the complexity. I’ll give you two difficult scenarios.

“Huge numbers of people treated in primary care who would have high scores on the PHQ-9 are in fact just lonely.” – Dr. James GriffithOne is disorder versus distress. If you simply download a Patient Health Questionnaire-9 off the Internet, give it to people: They have a high score; we say they’re depressed, give them an antidepressant. Huge numbers of people in primary care who would have high depression scores, in fact, are lonely; they’re in abusive relationships; they’re grieving losses; they are demoralized because their aspirations in life won’t take place – none of these problems are helped by an antidepressant.

Medical students, or for that matter, psychiatry residents, are not well taught in how to distinguish disorder from distress. All of these are solvable problems. There’s sort of a myth of the depressed patient that if only we would recognize depressed people, give them a prescription, everything would be okay, but it doesn’t.

Whitney: How do you teach that, then? What is missing in the curriculum?

Dr. Griffith: It’s a little bit like what Dr. Kirschner said about money and teams. You don’t have teams, if you don’t have funding. You don’t have teaching, if you don’t have time, and that’s one of our first issues.

People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, editorial board member of Clinical Psychiatry News and cohost of Mental Health Consult, and assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs at G.W. University School of Medicine & Health Sciences, and the medical director of psychiatric and behavioral services at G.W.U. Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington, and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine, Baltimore, and at the Uniformed Services University of the Health Sciences in Bethesda, Md.; Dr. April Barbour, an associate professor of medicine and the director of general internal medicine and of the primary care residency program at G.W.U. School of Medicine, Washington.

Dr. Beard: This is one of the major frustrations. You've hit it right on the head. I will take anywhere from 45-50 minutes to do this, and I will have others who are waiting in my reception area or I will have a tap on the door. It takes that kind of time and the unfortunate thing is, I am never adequately reimbursed for the time that it really takes. Often, what I do is ask my front desk to screen patients when they call. If they say it is a routine check-up, the front desk knows to ask, "Are there any particular concerns that you have this year. Anything you would like the doctor to focus on?" If they do, then what I have to do is block out three of my regular times and that is very costly.
 
Whitney: As we move into a world in which it is not fee-for-service—based and “I think if it’s possible to have a mental health professional on site [in your practice], it is a win-win situation.” – Dr. Lillian Beardwe have to create these new metrics, I say “we,” but the health care system is moving toward setting up new accountable care organizations or other sorts of bundle payments. When we have the new legislation take effect, the MACRA (Medicaid Access and CHIP Reauthorization Act) legislation, are you building into the metrics that you are going to be reimbursed through your third-party payers to include these 50-minute sessions or is there no way to do that?

Dr. Beard: I do not know of a way to do it. I really do not.

Whitney: How is that going to impact outcomes and reimbursement?

Dr. Beard: Well, it is definitely going to impact outcomes. One of the areas of interest that I have is the feasibility of having a mental health specialist in my actual primary care site. Even if it is for a few segments a week, it would be a tremendous help. Just having that individual present removes certain barriers. For example, there are times that, even during the primary care encounter, the mental health specialist is able to say to the patient’s parents, “We’ll be glad to make an appointment and discuss that with you at a future time, so we can go more in depth.” Just that introduction lowers the barrier. Otherwise, there is more resistance if I say, “I am going to refer you to Dr. Pickar he is an associate who…” They object, and want to know, “Well, what kind of doctor is Dr. Pickar? He is a psychiatrist?”  It depends on what association they have with the word “psychiatrist.” The parents might object, “My kid’s not crazy.” I have to explain that this is a mental health disorder that we can do something about, and the psychiatrist is going to assist us with that.

Dr. Pickar: That is a great model.

Whitney: Yes but is it feasible with all the new legislation that is coming down the line?

Dr. Barbour: I think there are very dramatic differences between the pediatric model of care, which tends to be more wraparound care that you are describing; (should this be “that” or “than”?) and the adult model of care, which is more consumer driven and in which we expect a lot of our patients. We find particularly that young people transitioning to their early 20s often have a hard time understanding how to interact in the adult model of care. Particularly the patients that we have worked on have had significant health problems, many of which include mental health disorders. The program that we put in place has some psychiatric services available in the clinic. That is not feasible – I think – in our current payment structure to do that everywhere, in all adult medicine clinics.

I think these patients are particularly vulnerable. They do not understand the health care systems. They come in with these diagnoses. You bring up ADHD and that is something an internist is not as comfortable in providing care for as you are, and that I think causes a lot of roadblocks for patients to get the medicines they need. It has worked well for them, but the new doctor is not as comfortable prescribing the medicine or making the diagnosis. There are issues around that.

Dr. Norris: This is one of points of the roundtable. Who should be delivering this treatment? If you can create a team based atmosphere where what Dr. Beard illustrated, just the introduction. "I want to introduce you to my colleague so that we can start treatment." That one element, just starting that can make a huge difference, but how do you make that fiscally viable? In the George Washington University Hospital Thriving After Cancer clinic, we used resident psychiatrist in training. These are senior-level residents who are very good at that or are supervised by a psychiatrist. If you were to put a psychiatrist in the TAC clinic and bill for their hours, it just would not work, Dr. Barbour is shaking her head like no way.

Dr. Barbour: I could not afford it.

Dr. Beard: What I am thinking is that this other professional, be it a psychiatrist or psychologist, a licensed clinical social worker, whatever, will have the capability of billing for his or her services. I think if it is possible to have that professional in your site it is a win/win situation.

People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, editorial board member of Clinical Psychiatry News and cohost of Mental Health Consult, and assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs at G.W. University School of Medicine & Health Sciences, and the medical director of psychiatric and behavioral services at G.W.U. Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington, and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine, Baltimore, and at the Uniformed Services University of the Health Sciences in Bethesda, Md.; Dr. April Barbour, an associate professor of medicine and the director of general internal medicine and of the primary care residency program at G.W.U. School of Medicine, Washington.

Dr. Beard: This is one of the major frustrations. You've hit it right on the head. I will take anywhere from 45-50 minutes to do this, and I will have others who are waiting in my reception area or I will have a tap on the door. It takes that kind of time and the unfortunate thing is, I am never adequately reimbursed for the time that it really takes. Often, what I do is ask my front desk to screen patients when they call. If they say it is a routine check-up, the front desk knows to ask, "Are there any particular concerns that you have this year. Anything you would like the doctor to focus on?" If they do, then what I have to do is block out three of my regular times and that is very costly.
 
Whitney: As we move into a world in which it is not fee-for-service—based and “I think if it’s possible to have a mental health professional on site [in your practice], it is a win-win situation.” – Dr. Lillian Beardwe have to create these new metrics, I say “we,” but the health care system is moving toward setting up new accountable care organizations or other sorts of bundle payments. When we have the new legislation take effect, the MACRA (Medicaid Access and CHIP Reauthorization Act) legislation, are you building into the metrics that you are going to be reimbursed through your third-party payers to include these 50-minute sessions or is there no way to do that?

Dr. Beard: I do not know of a way to do it. I really do not.

Whitney: How is that going to impact outcomes and reimbursement?

Dr. Beard: Well, it is definitely going to impact outcomes. One of the areas of interest that I have is the feasibility of having a mental health specialist in my actual primary care site. Even if it is for a few segments a week, it would be a tremendous help. Just having that individual present removes certain barriers. For example, there are times that, even during the primary care encounter, the mental health specialist is able to say to the patient’s parents, “We’ll be glad to make an appointment and discuss that with you at a future time, so we can go more in depth.” Just that introduction lowers the barrier. Otherwise, there is more resistance if I say, “I am going to refer you to Dr. Pickar he is an associate who…” They object, and want to know, “Well, what kind of doctor is Dr. Pickar? He is a psychiatrist?”  It depends on what association they have with the word “psychiatrist.” The parents might object, “My kid’s not crazy.” I have to explain that this is a mental health disorder that we can do something about, and the psychiatrist is going to assist us with that.

Dr. Pickar: That is a great model.

Whitney: Yes but is it feasible with all the new legislation that is coming down the line?

Dr. Barbour: I think there are very dramatic differences between the pediatric model of care, which tends to be more wraparound care that you are describing; (should this be “that” or “than”?) and the adult model of care, which is more consumer driven and in which we expect a lot of our patients. We find particularly that young people transitioning to their early 20s often have a hard time understanding how to interact in the adult model of care. Particularly the patients that we have worked on have had significant health problems, many of which include mental health disorders. The program that we put in place has some psychiatric services available in the clinic. That is not feasible – I think – in our current payment structure to do that everywhere, in all adult medicine clinics.

I think these patients are particularly vulnerable. They do not understand the health care systems. They come in with these diagnoses. You bring up ADHD and that is something an internist is not as comfortable in providing care for as you are, and that I think causes a lot of roadblocks for patients to get the medicines they need. It has worked well for them, but the new doctor is not as comfortable prescribing the medicine or making the diagnosis. There are issues around that.

Dr. Norris: This is one of points of the roundtable. Who should be delivering this treatment? If you can create a team based atmosphere where what Dr. Beard illustrated, just the introduction. "I want to introduce you to my colleague so that we can start treatment." That one element, just starting that can make a huge difference, but how do you make that fiscally viable? In the George Washington University Hospital Thriving After Cancer clinic, we used resident psychiatrist in training. These are senior-level residents who are very good at that or are supervised by a psychiatrist. If you were to put a psychiatrist in the TAC clinic and bill for their hours, it just would not work, Dr. Barbour is shaking her head like no way.

Dr. Barbour: I could not afford it.

Dr. Beard: What I am thinking is that this other professional, be it a psychiatrist or psychologist, a licensed clinical social worker, whatever, will have the capability of billing for his or her services. I think if it is possible to have that professional in your site it is a win/win situation.

People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, editorial board member of Clinical Psychiatry News and cohost of Mental Health Consult, and assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs at G.W. University School of Medicine & Health Sciences, and the medical director of psychiatric and behavioral services at G.W.U. Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington, and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine, Baltimore, and at the Uniformed Services University of the Health Sciences in Bethesda, Md.; Dr. April Barbour, an associate professor of medicine and the director of general internal medicine and of the primary care residency program at G.W.U. School of Medicine, Washington.

Dr. Beard: This is one of the major frustrations. You've hit it right on the head. I will take anywhere from 45-50 minutes to do this, and I will have others who are waiting in my reception area or I will have a tap on the door. It takes that kind of time and the unfortunate thing is, I am never adequately reimbursed for the time that it really takes. Often, what I do is ask my front desk to screen patients when they call. If they say it is a routine check-up, the front desk knows to ask, "Are there any particular concerns that you have this year. Anything you would like the doctor to focus on?" If they do, then what I have to do is block out three of my regular times and that is very costly.
 
Whitney: As we move into a world in which it is not fee-for-service—based and “I think if it’s possible to have a mental health professional on site [in your practice], it is a win-win situation.” – Dr. Lillian Beardwe have to create these new metrics, I say “we,” but the health care system is moving toward setting up new accountable care organizations or other sorts of bundle payments. When we have the new legislation take effect, the MACRA (Medicaid Access and CHIP Reauthorization Act) legislation, are you building into the metrics that you are going to be reimbursed through your third-party payers to include these 50-minute sessions or is there no way to do that?

Dr. Beard: I do not know of a way to do it. I really do not.

Whitney: How is that going to impact outcomes and reimbursement?

Dr. Beard: Well, it is definitely going to impact outcomes. One of the areas of interest that I have is the feasibility of having a mental health specialist in my actual primary care site. Even if it is for a few segments a week, it would be a tremendous help. Just having that individual present removes certain barriers. For example, there are times that, even during the primary care encounter, the mental health specialist is able to say to the patient’s parents, “We’ll be glad to make an appointment and discuss that with you at a future time, so we can go more in depth.” Just that introduction lowers the barrier. Otherwise, there is more resistance if I say, “I am going to refer you to Dr. Pickar he is an associate who…” They object, and want to know, “Well, what kind of doctor is Dr. Pickar? He is a psychiatrist?”  It depends on what association they have with the word “psychiatrist.” The parents might object, “My kid’s not crazy.” I have to explain that this is a mental health disorder that we can do something about, and the psychiatrist is going to assist us with that.

Dr. Pickar: That is a great model.

Whitney: Yes but is it feasible with all the new legislation that is coming down the line?

Dr. Barbour: I think there are very dramatic differences between the pediatric model of care, which tends to be more wraparound care that you are describing; (should this be “that” or “than”?) and the adult model of care, which is more consumer driven and in which we expect a lot of our patients. We find particularly that young people transitioning to their early 20s often have a hard time understanding how to interact in the adult model of care. Particularly the patients that we have worked on have had significant health problems, many of which include mental health disorders. The program that we put in place has some psychiatric services available in the clinic. That is not feasible – I think – in our current payment structure to do that everywhere, in all adult medicine clinics.

I think these patients are particularly vulnerable. They do not understand the health care systems. They come in with these diagnoses. You bring up ADHD and that is something an internist is not as comfortable in providing care for as you are, and that I think causes a lot of roadblocks for patients to get the medicines they need. It has worked well for them, but the new doctor is not as comfortable prescribing the medicine or making the diagnosis. There are issues around that.

Dr. Norris: This is one of points of the roundtable. Who should be delivering this treatment? If you can create a team based atmosphere where what Dr. Beard illustrated, just the introduction. "I want to introduce you to my colleague so that we can start treatment." That one element, just starting that can make a huge difference, but how do you make that fiscally viable? In the George Washington University Hospital Thriving After Cancer clinic, we used resident psychiatrist in training. These are senior-level residents who are very good at that or are supervised by a psychiatrist. If you were to put a psychiatrist in the TAC clinic and bill for their hours, it just would not work, Dr. Barbour is shaking her head like no way.

Dr. Barbour: I could not afford it.

Dr. Beard: What I am thinking is that this other professional, be it a psychiatrist or psychologist, a licensed clinical social worker, whatever, will have the capability of billing for his or her services. I think if it is possible to have that professional in your site it is a win/win situation.