A report in the May/June 2009 issue of Health Affairs reveals that at least two-thirds of 6600 primary care physicians (PCPs) were unable to obtain mental health care for their patients.1 The reasons cited include “manpower shortage” and “inadequate insurance coverage.” This extraordinary figure almost certainly includes problems with the referral process itself. Other factors may include the type of practice (solo vs group) and its location (rural vs urban).
Psychiatrists helping nonpsychiatrists refer their patients has a long but not always illustrious history. Patients admitted to a general hospital with emotional disorders are said to account for 25% of all admissions, yet referrals to consultation-liaison services rarely exceed 10%.2,3 And studies that have examined the detection and/or management of depression and other affective conditions in primary medical practice report a disappointing 50% failure rate.4 PCPs, as de facto mental health providers, are generally the first contact for individuals with emotional disorders; as such, it would be reasonable to expect a more robust referral rate.5
It is unlikely that much can readily be done to remedy manpower or reimbursement factors, but reexamination and possible modification of referral practices may enhance the availability and use of mental health services. The education and training model endorsed and promoted for decades by professional organizations such as the AMA, the American Psychiatric Association, the NIMH, the Institute of Medicine, and others has been a startling failure.6-8 Psychiatrists helping PCPs facilitate appropriate psychiatric referral may be a place to begin.
Barriers to effective referral present a challenge to both PCP and psychiatrist. Awareness of these impediments will help show the PCP how to minimize failure and disappointment. Some of these factors were identified at least 30 years ago, but a reevaluation in the context of today’s health care system is warranted.9 A partial list of barriers to successful referral appears in Table 1.
. . . not all evidence of psychosis requires referral; burned-out schizophrenia, for example, is readily managed and maintained by the PCP, with psychiatric backup.
Differences in tolerance of affect as well as training will influence awareness of psychosocial problems; medical education that emphasizes the biomedical model does not readily shift to a biopsychosocial one. Styles of interviewing and listening as well as beliefs affect the nature of physician-patient relationships. Stigma still prevails and fosters fear, apprehension, and distorted views of mental illness and psychiatry. Various specialties differ in their reliance on interviewing, technology, and laboratory results. Ultimately, funding and reimbursement are profound incentives (or disincentives) for both physician and patient to use available services.
Given these obstacles to incorporating a psychiatric dimension in primary care, psychiatrists must not expect PCPs to become “junior psychiatrists.” Psychiatrists learn skills of interviewing and working with patients in a time- and labor-intensive multiyear process of supervision and clinical experience that cannot be transferred to nonpsychiatrist physicians in brief courses, workshops, lectures, and seminars.
How can psychiatrists help?
How, then, might psychiatrists help their nonpsychiatric colleagues recognize the need for and successfully execute psychiatric referral? Effective referral begins with a good consultee-consultant relationship that includes familiarity with each other’s needs and idiosyncracies. While not routinely easy to initiate, occasional encounters may occur in institutional settings, as well as other settings. Helping PCPs familiarize themselves with mental health services and competent psychiatrists is a helpful beginning. Effective referral will, in part, hinge on expectations and knowledge each has of the other.
To calibrate expectations of the PCP, the psychiatrist should be cognizant of the enormous burden the PCP carries in his or her daily practice.9,10 Paraphrasing Gilbert and Sullivan, the PCP’s lot is not a happy one. One observer of the crisis in primary care states, “Patients are increasingly dissatisfied with their care and with the difficulty of gaining timely access to a primary care physician; many primary care physicians, in turn, are unhappy with their jobs, as they face a seemingly insurmountable task; the quality of care is uneven; reimbursement is inadequate; and fewer and fewer US medical students are choosing to enter the field.”10 It helps for psychiatrists to keep this reality in mind when assessing the difficulty or “reluctance” of their PCP colleagues to make psychiatric referrals.
The responsibility for detecting, diagnosing, and treating mental illness in patients who themselves frequently deny or are unaware of their problems is, indeed, a challenge. Whenever the PCP feels unable or inadequately trained to treat, a cornucopia of specialists of all disciplines exists for thoughtful referral. Psychiatry is only one of many specialties for which the PCP offers triage, gatekeeping, and coordination. In cases in which neither patient nor PCP considers the possibility of pertinent emotional perturbations, psychiatric referral is unlikely to occur. If, indeed, as Bodenheimer11 states, “The knowledge and skills [PCPs] are expected to master exceed the limits of human capability,” then PCPs themselves may need sympathetic support and guidance more than criticism and instruction in how to refer patients. Because past clinical experience reveals a high nonconcordance and nonadherence rate with suggestions for management, special effort must be made to improve direct communication, to clarify purpose of referral, and to incorporate diligent follow-up.12
Primary care physicians (PCPs) often have difficulty in making a psychiatric referral; the psychiatrist consultant may help by making a special effort to improve communication, to clarify purpose, and to emphasize the importance of diligent follow-up.
Encouraging the use of newer means of communication (eg, e-mail, telemedicine) may facilitate information exchange between the psychiatrist and PCP (with attention to privacy and medicolegal concerns), but consultative input should be free of jargon, practical, and readily applicable.
Patients with psychiatric disturbance may be especially sensitive to implications of rejection or desertion; therefore, patients should be reassured that they will not be abandoned by their PCP.
The difficult patient’s symptoms must be believed and respected; basic physical workup is essential at every visit, although endless pursuit of organic causes should be curtailed.
Communication is the key to success
Your local PCPs will be forever grateful for whatever you, as a psychiatrist, can do to ease their burden. By expressing your awareness and appreciation of the unusual burden they sustain, you can let them know why it is so difficult, as they frequently complain, to obtain access to mental health consultation or clinical services. You can tell them why and how psychiatrists are different, and why they are rarely able to accommodate acute referrals at short notice.
Often, nonpsychiatrist physicians are not aware that “traditional” psychotherapists may spend as much as 45 to 50 minutes with a patient: the therapist cannot be interrupted any more than a surgeon can be interrupted in surgery. You can promise callers to always return calls by day’s end and to send them a clinical note about any referral. They will need an explanation why information that might violate confidentiality or that has little relevance to the stated reason for referral will not be shared. Some PCPs prefer face-to-face (or voice-to-voice) feedback, since they “may not have time” to read lengthy reports.
Newer means of communication (eg, e-mail, telemedicine) may facilitate information exchange (being cognizant of privacy and medicolegal concerns), but any feedback should be direct, basic, free of jargon, and readily applicable. Notes to the PCP regarding his patient’s medication changes, emergency department referral, or hospitalization must be transmitted promptly. PCPs do not have time for, or interest in, lengthy psychodynamic narratives.13
If you work in a hospital or other institution that psychiatrists and other physicians frequent, you might distribute 1-page descriptions of what services are available in your mental health network and a biographical note about yourself, with indications of telephone hour(s) when they might reach you directly. Every effort should be made to return all calls the same day. Just because you cannot accept new referrals is no reason not to respond to calls. Occasionally inviting a doctor to lunch or for coffee (if you both have the time) is a cordial way to cement a working relationship and counter the accusation that psychiatrists are an insular group. Offering to do grand rounds or volunteer teaching at your institution is a good way to promote psychiatry without proselytizing.
The nature and extent of recommendations made in consultation usually depends on deciding collaboratively whether the PCP or the psychiatrist will provide ongoing psychiatric management. One study demonstrated that a consultation letter to PCPs on how to manage patients with somatization disorder produced improved outcomes and considerable economic savings.14
Explain to your PCP colleague that consultation is not a one-time encounter and that you can be available to help with follow-up and medication advice (even in “curbside” chats). But you should also emphasize that regularly scheduled brief appointments (eg, monthly), with emphasis on the need to maintain medication regimens, are essential. Reimbursement for such “maintenance treatment” may require that the PCP endure some aggravation with insurance companies about the necessity (and economy) of such management techniques. Time constraints that cause omission of these dimensions of care will render the consultation useless. Ancillary health care staff can fulfill some of this responsibility, but patients regard the physician’s interest, care, and support as part of the treatment.
It is important to tell your PCP colleague that patients with psychiatric disturbance may be especially sensitive to implications of rejection or desertion; therefore, patients should be reassured that they will not be abandoned by their PCP. Telling patients about physician absences for extended times for vacation or meetings will help reduce patient anxiety, avoid symptom augmentation, and maintain stability.
Preparing the patient
Psychiatric referral involves levels of complexity not experienced in other specialist referrals. For example, little time, explanation, or preparation is required to refer a patient to a cardiologist for study of a newly discovered murmur. Conversely, preparation for a psychiatric referral may require unusual tact, time, and explanation. If you suspect that the PCP is uncomfortable or feels awkward making the referral, you can offer to provide tips on ways to lubricate the process; if your office is in the same building as your PCP colleague’s office, you could either meet the patient in the PCP’s office or ask that the PCP walk the patient to your office for a personal introduction.
The precise way in which the need for referral is presented may be complicated by implied disbelief of the patients’ symptoms, the patient’s fear of rejection, confusion about what to call a complaint presented as physical but now termed emotional, and uncertainty about what to request in the consultation. PCPs often undervalue their own psychological awareness and know that explanations such as “there is nothing wrong with you,” or “you need to see a psychiatrist,” or “it’s all in your head” are not only ineffective but are also potentially harmful and can disrupt a good physician-patient relationship.
You can suggest a softer, more tolerant approach: “I think your symptoms may be related to the stresses in your life that we have discussed; they can cause changes in metabolism or physiology, even pain. Just as I am not a specialist in cardiology or urology (or others), I am also not a specialist in the many ways stresses can affect the body. I would like you to see someone who does specialize in that field to see whether there are things we can do together to help you get some relief. After you have seen Dr X, I will continue to see you to implement his suggestions.” You may need to tell the PCP that a patient may require several visits before he can hear and understand that he is being referred to a psychiatrist.
Again, reassuring patients of the continuing relationship with the PCP is critical because patients incorrectly assume that a referral means termination of the primary care relationship. Caution physicians against overpreparing patients for referral, which can happen when patients have symptoms of anxiety, distorted ideas about psychiatry, and uncertainty. A straightforward, brief statement is likely to be more effective: “The consultation will help me to help you better.”
When to refer
PCPs do not necessarily know that not all psychiatrists, even those highly esteemed in the community, are adept at providing consultation. Those with training and experience in psychosomatic medicine and consultation-liaison psychiatry or addiction medicine are often more accustomed to working with patients with comorbid illnesses or diseases. Much physical (or surgical) illness is accompanied by heightened affective responses, such as depression and anxiety. Diminution or abatement of these responses may occur when the physical condition improves; however, persistent symptoms should not be dismissed as a normal reaction to an illness. Remind PCPs that the physical and the emotional resonate with each other: improvement in one usually accompanies improvement in the other. Chronic depression has been shown to negatively affect a variety of physical diseases, for example, cardiovascular disease, Parkinson disease, Alzheimer disease, and diabetes.15
Generally, PCPs do not need to be advised about reasons to refer. They are likely to seek consultation whenever they feel uncomfortably in over their heads (Table 2). However, they may not know that often patients who commit suicide have visited their PCP sometime during the preceding 2 weeks. Remind PCPs that any concern about suicidal ideation warrants prompt consultation; you must assure them that you are available if they uncover evidence of suicidal thinking.
On the other hand, they may not realize that not all evidence of psychosis requires referral; burned-out schizophrenia, for example, and other quiescent psychoses are readily managed and maintained by the PCP, often with psychiatric backup. Of course, questions of diagnosis in depression, anxiety, and other disorders deserve psychiatric assessment, because help may be required in recognizing these disorders.
PCPs can be assured that some acute reactions may resolve spontaneously or with medication and support, but suggestions of chronicity warrant consultation. Failure of the patient to complete the referral process requires persistent follow-up and encouragement by both you and the PCP.
If you have a good working relationship with one or more nonpsychiatric colleagues, you may be able to advise about when other kinds of problems may benefit from consultation, such as developmental issues in children or adolescents, sleep problems, conflicts with sexuality, substance abuse difficulties, or family dysfunction. Your PCP colleagues may be surprised when you recommend other specialist psychiatrists for these various problems. You can instruct them to contact your local district branch of the American Psychiatric Association for names of specialists in various areas or provide them yourself.
It may puzzle a PCP to hear that most patients who are recently bereaved do not require psychiatric referral or even medication, unless their symptoms become chronic after 6 months. The psychiatrist can advise about the importance of listening to the patient during scheduled visits; sometimes all the patient needs is an understanding person to talk to.
Most PCPs have a rudimentary knowledge of psychopharmacology and therefore may not use or monitor drug treatment effectively. If you consult on such treatment, it is useful from time to time to ask the PCP for feedback on the patient’s response. Inviting the PCP to be in touch if things do not work out as hoped may help modify his expectation of some kind of magical cure and encourage him to keep avenues of communication open for management revision; curbstone conferences, e-mail, or a telephone conversation can serve this purpose. In the event of evidence of a dementia, you may want to suggest how the PCP can make an early tactful referral to a neurologist or psychiatrist in a way that minimizes the patient’s fear.
The difficult patient
You will no doubt have heard your PCP colleagues frustratingly and pejoratively refer to their “hateful patient,” “problem patients,” “frequent fliers,” “turkeys,” or “crocks” and the anguish these patients cause them.16,17 Because these patients frequently interfere with good physician-patient relationships and are the most difficult to refer, providing management tips in a prereferral discussion may be appreciated.
For patients who cannot or will not be referred, helping the PCP with management will make his life immeasurably easier. Every general practitioner occasionally encounters patients who make them feel frustrated, angry, and helpless. Most often, the patients who challenge the physician’s skill and tolerance are those with medically unexplained symptoms, somatization, and hypochondriasis.
Psychiatrists are often no better than the PCP at managing these patients. Because patients with medically unexplained symptoms rarely accept referral for psychiatric consultation, PCPs should familiarize themselves with the literature on management guidelines for this relatively large population of troubled and troubling patients.18-24 Personal discussion and case review between PCP and psychiatrist often help map a management strategy for the patient and reduce frustration for the physician.
To help PCPs manage difficult patients more satisfactorily (and comfortably), you can suggest several principles of management (Table 3). PCPs should explore the patient’s psychosocial history very slowly and not jump in with psychological explanations. These patients speak the language of the body (physical) and cannot readily be converted to the language of the mind (emotions).
The patient’s symptoms must be believed and respected as valid, and the temptation to label must be avoided. Basic physical workup is essential at every visit, although endless pursuit of organic causes should be curtailed, as should multiple prescriptions and referrals, saying something like “We have already tried all the medicines that could help; you do not have anything fatal and it is better for us to get to know more about you before trying anything else” may help.
Emphasize to the PCP that of greater importance than remission of symptoms is a trusting physician-patient relationship and assurance of its continuity through regularly scheduled (brief) appointments. Expressions of frustration to the difficult patient have only a negative effect. In time, in the context of such a relationship, symptoms will begin to remit. Patience and modest expectations will reward both patient and physician with better outcomes and greater satisfaction.
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