We live in the age of the specialist. Physicians migrated toward clinical specialties years ago, enjoying praise for their expertise and exalted levels of income. The general practice model of primary care is less respected and less well compensated. This shift to a narrow, specialized focus is recommended today for those developing skills of all kinds.
Scientific research focuses on specific diseases, cells and genetic material to find cures. This narrowing of one’s range of focus may start early in life. We celebrate prodigies, and some parents hasten the focus and training. Tiger Woods was celebrated in the media for his golf skills at age 5. Yet Roger Federer, another champion, settled on tennis much later since his parents let him try many sports.
These issues are analyzed at length in “Range,” a book by David Epstein on the relative value of specialization and generalization. Rule-bound, repetitive pursuits like sports can benefit from early specialization and deliberate practice. Yet innovation and problem-solving are different. Epstein cites extensive research to argue that we can solve many problems by expanding our range of focus.
He argues that our greatest strength is the exact opposite of narrow specialization, and suggests:
The challenge we all face is how to maintain the benefits of breadth, diverse experience, interdisciplinary thinking, and delayed concentration in a world that increasingly incentivizes, even demands, hyper-specialization.
These thoughts were brought home to me recently in exploring the interface between behavioral health and primary care. A colleague guiding me through the complexities of the PCP’s world, Norm Ryan, MD, coined a term for how behavioral health needs to be infused into the work of the primary care physician. Behavior must be considered with every diagnosis, or Behavior in All Diagnoses (BiAD).
This mnemonic is a useful tool for the PCP. The perspective underlying it stands in contrast with the widely heralded “collaborative care model.” That model prescribes how PCPs and psychiatrists can improve the treatment of psychiatric disorders in primary care. Alternatively, PCPs using BiAD are reminded how there may be a behavioral element of the disease or the care for every medical diagnosis.
Collaborative care sets up PCP protocols to ensure psychiatric best practices are followed for mental health diagnoses. PCPs see a bigger problem that BiAD addresses. Every diagnosis could have a critical behavioral component. Some patients do not follow treatment recommendations. Others will not change their lifestyle. They may present reasons that are trivial or heartfelt for not changing.
Behavior may feed the disorder or complicate the treatment. Behavior drives clinical results for many medical conditions, and not just for patients with diagnosable behavioral health disorders. PCPs need a behavioral colleague in their office to help with patients they cannot reach or understand. Behavior is a question with every diagnosis, and behavior change expertise is necessary in primary care.
Diagnosis is of paramount importance to PCPs. They are presented with undifferentiated patient complaints at each visit, and they need the skill to select from the full compendium of disorders. The process is often one of ruling out possible diagnoses until one emerges as most likely. A psychotherapist in this setting also works as a generalist, driven less by diagnostic concerns than by psychosocial issues.
Consider a clinical example. An overweight person develops metabolic syndrome with risk for heart disease, stroke and diabetes. BiAD is a reminder for the PCP to explore behavioral issues. A therapist may note subclinical depression related to marital conflict, and maladaptive coping through overeating and alcohol use. The PCP and the psychotherapist ideally work together in the same office.
The therapist’s work in this example is not related to diagnoses covered by insurance. The focus instead is the early stages of depression and addiction (that an EAP benefit addresses), along with unhealthy eating behavior (that wellness benefits address). Incidentally, this case shows why EAP and wellness benefits belong in the primary care setting. PCPs using BiAD will direct many people to these benefits.
The PCP must remember that behavioral issues are potentially relevant with every medical diagnosis. The behavioral health clinician is there to diagnose behavioral health disorders, prevent the progression of maladaptive patterns into clinical conditions, and understand the complexity of unhealthy behaviors that drive chronic disorders. Care is comprehensive first, and it is collaborative as needed.
The primary care setting needs generalists who know medicine and behavior. Narrow specialization is needed after the PCP and the psychotherapist do their jobs well. It may then be time for specialists like cardiologists and psychiatrists. The frontlines of care require a breadth of focus that is best called, comprehensive primary care. Behavioral health is a core component of it, not a collaboration.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.