A New Year, A New Model of Mental Care

Stephen M. Strakowski, MD


January 17, 2017

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Hello. I'm looking forward to talking to you today about something that is a little different from my typical videos, although it follows a previous discussion of how we are creating our new department at Dell Medical School at the University of Texas at Austin. Today I want to talk about how the role and job of psychiatrists is going to have to evolve in our country to meet needs.

As most of you are aware, we are currently not meeting society's needs and requests for good mental health care. The demand is truly overwhelming, rapidly overwhelming virtually every office and health system that employs psychiatrists. Almost immediately, a psychiatrist's practice fills. The way they are set up, mostly because the demand is so high, many private practitioners don't join any insurance panels. Consequently, although the wealthy can typically get care, insured middle-class people cannot. Of course, if you are poor, you have limited resources and are often plugged into the public system, which is typically undersourced.

A big, central part of this is psychiatrists. Not surprisingly, it turns out that psychiatrists are the most expensive part of the care pathway, and they are also the least available. It is highly unlikely that either of these things is going to change anytime soon. There is no evidence whatsoever. There is a dramatic shift in medical schools of [fewer] people going into psychiatry, and it is unlikely [that either of those things are] going to happen. Additionally, there is no evidence that reimbursements within insurance panels are going to dramatically go up so that psychiatrists will open their practices to panels.

We need to think about different ways to deliver care in order to improve psychiatric and brain health conditions like depression, bipolar disorder, and schizophrenia. To meet that need, we have to change our roles as psychiatrists. I have nothing against a cash-based private practice, and everyone should do what they feel they do best. As a discipline, we have some obligation to try to meet the needs of society. One might argue that because most of our residencies were paid at least in part by Medicare dollars, perhaps we do have more obligation than we often think about.

We are not meeting the demand. We are not getting to people who need the care most.

What does that mean? Well, the traditional role of the past 50 years, where psychiatrists saw patients for 30-50 minutes for medication/psychotherapy visits, is probably not sustainable. Psychiatrists are too expensive, and the throughput for patients is just too slow. We are not meeting the demand. We are not getting to people who need the care most. That means we are going to have to practice differently. How is this going to look? I am going to give a quick summary and then we will talk about a possible future care pathway for us to at least start considering.

First, psychiatrists have to become members, if not the leaders, of multidisciplinary teams where roles are assigned to allow people to provide practice at the top of their license, ideally assigning the lowest-cost person who provides the best value. It doesn't mean that we are trying to be cheap. It does mean that we are trying to place the care within a cost bucket that makes sense for that type of care.

The psychiatrist's role in that type of structure is to be the expert in medical assessment, diagnosis, and overall care planning because psychiatry is the only discipline to train across the different care modalities. It is important to keep in mind that psychiatrists are not necessarily the experts in, for example, psychotherapies, but they are the experts on how to integrate medication and psychotherapy most effectively.

Psychiatrists have to function as physicians. We cannot continue to function as psychologists, social workers, and case managers.

Basically, psychiatrists have to function as physicians. We cannot continue to function as psychologists, social workers, and case managers because there are better-trained people who can do that, who are more available, and whose cost could be aligned to fit the care more effectively.

We cannot clog our schedules up with routine follow-ups, routine medication management, or most therapies that other providers can provide. When our schedules are full, we are not available to do those first assessments that are most critical in a patient-centered model. Again, the big shift is to move away from physician-centered practice to patient-centered practice, and that is going to be the challenge.

The psychiatrist's job is to hold the team accountable for evidence-based care. One of the paradoxes of the wealthy getting cash-based care is that they are often receiving it from people who are not practicing care that is based on current evidence. We as the physicians on the team need to hold the team accountable to the evidence. The psychologist on the team is critical in holding the therapy piece accountable for evidence-based therapies. Therapies are perhaps among the most poorly managed. Psychotherapy is a poorly managed group of evidence-based care products that we have. The psychiatrist's role ends up being much more of a consultant—a specialist like other medical specialties—to primary care providers, including OB/GYN, therapists, and case managers, rather than being the primary care provider.

Historically, the way most of us were trained was to be kind of a primary care provider who happened to have specialty skills and did everything. We are too expensive and too rare for that to continue, or we will never meet the need. What would a new pathway look like?

There are many places that are starting to move this way, although we have yet to declare our evidence base in a way that is clear and consistently applied. But that is a different discussion. The pathway would look something like this: When there is a referral for psychiatric care, it comes to a team from other physicians or other mental health providers, and then a decision has to be made—a triage decision of whether a psychiatrist should evaluate the patient or, if the presentation is clear enough or the patient needs therapy without medication, it can be done by a psychologist.

At this point, let us assume that the psychiatrist should provide a medical evaluation for every patient. The psychiatrist does that evaluation. There is a team meeting about the patient's needs, and in that meeting, the needs are met by assigning the best person to do that care. Again, here is where we often trip up. A grandfather of a friend of mine once said that when physicians go to medical school, they come out knowing everything about everything. We really can't do that anymore. We have to acknowledge that other people can do a lot of what we do, just as effectively. That is part of moving these teams forward.

After the care is distributed, if it is a routine case where the primary care doctor can prescribe the antidepressant and the social worker can provide good cognitive-behavioral therapy, there is no need for the patient to continue with the psychiatrist. If it is a complex case, then the psychiatrist may need to stay engaged. For example, a complex bipolar patient may have a lot of medication management issues that are going to continue for at least the first few weeks of treatment. In that case, the engagement remains until the patient is stabilized and can be handed off. A hand-off needs to be part of the consideration. Otherwise, the psychiatrist's practice will fill up with follow-ups and not be available to do this critical first step.

Medication care goes back to the referring physician, a nurse practitioner, or other member of the team whenever possible. Psychotherapy is probably provided by trained social workers or other mental health counselors who are supervised by psychologists who will jump in to care for complex patients. The psychiatrist gets re-engaged if treatment is not going well or if outcomes are not being met.

Central to all of this is a much more systematic approach to measuring outcomes, rather than the gestalt that exists in most practices where people seem to be getting better. We need to challenge ourselves to raise the bar in that area, particularly because we don't have laboratory values or imaging changes that we can measure, like in some branches of medicine. In fact, most branches are like us, frankly.

This approach is going to require a major shift in our culture. This is not how I was trained. I am old enough to have been trained in a way such that when I take on a patient, the patient and I work together indefinitely unless one of us dies or moves. This model looks a lot more like what surgeons have been doing for many years in concert with physical therapists and medical assistants. Because surgeons are so expensive, we quickly recognize that they cannot continue to do routine follow-ups.

Psychiatrists, unfortunately or fortunately, also need to think about that and about how we changed our roles. Many of us went into psychiatry because we like working with people, but we are going to have to shift how we think about that. We are still working with people but in a different way, and our ability to get to know our patients is not going to be trivialized if this is done effectively.

Here at the University of Texas at Austin, we are trying to tackle this problem to figure out how we can move our field to be able to manage the enormous demand for mental healthcare that we are absolutely failing to meet. The model that I have suggested is not uniquely mine, by any means, and at least pieces of it are being adopted in some places.

The big challenge I bring to all of the organizations that are starting to do this is to be much more rigorous about using evidence-based treatments and much more rigorous about measuring outcomes. Hopefully, this will be useful. I look forward to any comments people have about this. It is intentionally provocative. Thank you.


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