Healthcare reformers try to convince us that transforming our giant healthcare system is achievable. A recent effort in Health Affairs starts by framing the magnitude – our $3.7 trillion healthcare system is larger than the total economy of all but three countries – and then suggests we chip away at the excess 1% at a time. This will hopefully add up to big change eventually.
While this may not reassure many people, it does reinforce an important point. Advocates for change must stay realistic. Strategic plans are essential but insufficient. Attend to practical issues. For instance, are all key players at the leadership table? This question has relevance in my work toward consolidation with primary care. Where are the psychiatrists? Can reform succeed without them?
My plan for a better future for our field rests on two main ideas. We should shift behavioral clinicians into the primary care setting and fundamentally reconstitute it. We should leverage the power of psychotherapy in that setting and modify it to address both psychiatric and medical disorders. The primary focus may not be on psychotropic medications, but it must embrace the skills of psychiatrists.
Many others in our field have called for collaboration with primary care, but rarely has the general power of psychotherapy been the motivating force. Some psychiatrists want to improve PCP prescribing patterns. Specialists have programs for smoking cessation and overeating. Yet the call to action here is broadly focused and directed at PCPs. The goal is to attract PCPs to a new model for their work.
PCPs are more motivated to consider this plan than clinicians in our field. The crisis in primary care has been dire and deteriorating for years. Behavioral healthcare bumps along as an underfunded specialty. While many clinicians may express discontent, our field is not in crisis. Psychiatrists have been especially fortunate to find a comfortable niche managing medications and doing little psychotherapy.
Why do we need psychiatrists leading behavioral healthcare reform, especially a model grounded in psychotherapy? The answer lies in two other questions. If the idea is to merge with primary care physicians, why would behavioral health physicians be left out? Why would those with the most advanced degrees and training within our field be left out? We need leadership from those ranks.
Leadership from psychiatry does not mean support from most psychiatrists. There are diverse views within the ranks of psychiatry. Some are skilled in both psychotherapy and psychopharmacology. Psychiatric leaders bring a certain credibility and perspective that non-MD therapists lack. For example, they understand medical conditions better than other behavioral clinicians.
These dynamics are complicated, and yet the hope holding these alliances together is the potential for a radically new patient experience. This new model, comprehensive primary care, promises greater achievements in prevention, health improvement, and disease management than existing models. Many PCPs are ready to lead, and it is the time for psychiatrists to join the leadership team.
The isolation of psychiatrists in their private offices is extreme. PCPs rarely encounter any. Many psychiatrists have consulted from afar with PCPs, and yet this is not the same as functioning on the frontlines. PCPs are results-oriented and welcome any means by which colleagues might change behavior for their patients. They welcome therapy, medication, or any combination of the two.
Our field needs an invitation from PCPs to enter their existential crisis. Any reconfiguration of the primary care setting in which behavioral health clinicians feel “at home” must start with PCPs embracing that vision and actively collaborating. There are probably as many creative pioneers within the ranks of psychiatry as any other profession. How do we lure a few of them to the frontlines?
Consider this enticing idea. The proposed reinvention of primary care contains a similar opportunity to reinvent psychiatry. Psychiatrists have more knowledge of both mind and body than other clinicians. Yet the interface between them is not well understood since each entity tends to be studied separately. Psychiatrists might gain new insights on this relationship in a setting that is a mind-body melting pot.
Patients in the primary care setting present diverse somatic complaints with psychological origins. Psychotherapists may be able to help with underlying emotional pain, but psychiatrists may be able to pierce this mind-body interface in ways not understood to date. This is just one possible avenue for innovation, but the main idea is that primary care offers exciting possibilities for curious psychiatrists.
Let us return to the idea of amassing 1% solutions. This perspective applies to building a leadership team. We do not need most clinicians to embrace the ideas here. We need a few strong leaders who understand that institutions often appear precarious only in retrospect. Prepare for crisis. PCPs ignored warning signs about their field for years. Behavioral healthcare will benefit from a bigger, better home.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.