Microsoft word - nease leiden paper 17-10-2008.doc

Paper presented at The First Dutch Balint Conference, Oegstgeest, Netherlands, Oct 17th 2008. Can primary care recover patient-centered medicine? Donald E. Nease, Jr., MD President, American Balint Society Vice President, International Balint Federation Associate Professor of Family Medicine University of Michigan – Ann Arbor, Michigan USA Introduction First, I would like to say a word of thanks to Marieke van Schie for her kind invitation to speak at this meeting. I wish also to bring all of you greetings from your Balint colleagues in the United States. These are interesting and difficult times for many of our nations and our world, as you are certainly aware. I’d like to bring you today a view of our situation in primary care in the US. Primary care, or more specifically Family Medicine, known to the rest of the world as General Practice, is also in many ways under critical stress in the US. The US spends more per person ($6401 in 2007) on health care than any other country, yet has mortality and overall health statistics that trail most Organization for Economic Co-operation and Develompent (OECD) nations(1). In this context primary care is especially stressed as dollars in our quasi free-market system flow toward the most highly technical and procedurally oriented specialties. As a result, primary care has extreme difficulty filling its ranks with new medical school graduates, showing the lowest fill rate with US graduates in 2007(42.1%)(2), and rates of visits to family doctors are on the steady decline, comprising 24% of total outpatient visits from 2000-2003(3). The absence of patient-centered medicine in primary care Coming around to the topic of this paper, why do I speak of a need to “recover” patient-centered medicine? Simply stated, in the context of primary care and family doctors being under severe stress, their ability to practice patient-centered medicine is limited, even if they’ve been trained or are attuned to it. Primary care is now, more than ever, being driven to greater emphasis on illness-based care. As one example, the chronic care model (CCM) developed by Wagner and it’s growing popularity as a way to address an ever-growing burden of diabetes, asthma, and heart disease, does not explicitly address patients as whole persons, instead they are collections of chronic diseases(4). As a result, the CCM has encouraged the development of industries of disease management, each focused on an specific condition, so that a patient with diabetes, depression and heart disease can get calls from three different care managers from three different organizations, none of which may be aware of the other’s activities. Paper presented at The First Dutch Balint Conference, Oegstgeest, Netherlands, Oct 17th 2008. Indeed even the term “patient-centered” seems to be under stress these days, having found its latest incarnation in “patient centered medical homes” (PCMH). This recent terminology and definition has been embraced by primary care specialty organizations in the US and by the major private health insurance company quality standards organization, the National Committee for Quality Assurance. Incentives are being put in place to encourage practices to meet the elements of a PCMH. In their definition, practices that are PCMH “homes” are defined as little more than collections of functions such as maintenance of lists of patients with chronic diseases and electronic reminder generation based on evidence-based guidelines. Now, these functions are not bad in and of themselves, but to equate them with patient-centered medicine stretches the concept to the extreme. As Berenson and colleagues comment in the current issue of the journal Health Affairs: “Our concern is that in moving so decisively to emphasize new responsibilities that implicitly assume reliance on various EMR functions and adoption of the challenging elements of the CCM, current PCMH recognition standards may leave behind crucial aspects of patient-centered care and the physicians who provide it.” (5) Just as with the CCM, a new industry of consultants has arisen to help primary care practices adopt the PCMH standards, but none of these consultants address listening and reflection as an important and necessary aspect of patient-centered primary care. Patient-centered medicine – the Balint perspective Having touched briefly on the latest reinterpretation of patient-centered medicine, let us return to the origins of the term. In the United States, many are surprised to learn that the term and concept originated with Michael and Enid Balint, despite this being acknowledged by the North American popularizers of the term from the University of Western Ontario. Enid Balint states the definition quite succinctly in her paper, “The possibilities of patient –centered medicine:” In contrast, there is another way of medical thinking which we call 'patient-centred medicine'. Here, in addition to trying to discover a localizable illness or illnesses, the doctor also has to examine the whole person in order to form what we call an 'overall diagnosis'. This should include everything that the doctor knows and understands about his patient; the patient, in fact, has to be understood as a unique human-being. The illness which can be described in terms of a 'traditional diagnosis' is either an incident like a broken leg, or a part like accident proneness which makes better sense if understood in terms of the whole. (6) Enid and Michael sought to challenge primary care doctors like myself to go beyond the broken leg to see the whole patient. As we all know, for some patients this whole patient perspective can come quite easily to the doctor. Patients that are well Paper presented at The First Dutch Balint Conference, Oegstgeest, Netherlands, Oct 17th 2008. integrated, and come to their doctor ready to engage provide an easy avenue for joint exploration into what lies just beyond the illness. Whether we as doctors are ready to engage with them in that exploration is another matter, and this readiness is one, if not the, major benefit to the Balint perspective gained through Balint group experience, specifically, an openness to a patient-centered exploration. However, just as often, perhaps, the patients are not open to this exploration, and here matters may proceed without incident for quite some time until deeper waters are unwittingly entered. An illness may fail to resolve as quickly as expected, a sudden and unexpected life stress may present or suddenly one of the parties in the relationship may realize something is missing. Here one finds another major benefit of Balint training, the doctor is prepared with an understanding that deeper waters may be entered with care and confidence. Primary care & mental health – a historical perspective Of course a major area where patient-centered medicine comes, or at least should come, into play in our day to day work as GP’s is in the area of mental health or psychological problems. I use the term “problems” here very intentionally rather than “illness” or “disease.” Indeed here is the crux of the issue. Studies examining the rates of mental illness in GP’s waiting room patients are striking. The conventional wisdom from these studies that is widely quoted proposes that as many as 40% of our patients suffer from mental illness of which we recognize only half, and even worse of those that we recognize we only treat half appropriately. In the US these numbers have fueled a large number of studies examining screening and treatment of mental illness in primary care. Most of this work has been led by psychiatrists with little collaboration or input from primary care. Here I must point out that from an academic standpoint, psychoanalytical psychiatry has no standing or input into this work in the US. Illness based medicine would seem to be winning the day. Callahan and Berrios in their book “Reinventing Depression” take a broad historical view of primary care and its work with psychological problems(7). Their work highlights several important points: psychological problems in primary care are no more or less common today than in the past, and biological models for mental illness, especially for depression and anxiety, have become so dominant that social and other determining factors are nearly forgotten, and primary care despite being the locus of care for the vast majority of psychological problems has had little impact in guiding the field. Manufacturers’ evidence: The drug “doctor” vs. drug companies The dominance of biological models of psychological illness has reinforced the “illness-centered” approach within primary care. Again the perspective of Callahan and Berrios reminds us that whether it be bromides in the 1930’s or serotonin reuptake inhibitors today, there has never been a great reluctance to prescribe medications to ease psychological distress. The shift has come in the massive marketing of these agents to primary care and in the US directly to patients. Paper presented at The First Dutch Balint Conference, Oegstgeest, Netherlands, Oct 17th 2008. Psychiatry has also played their part with research emphasizing primary care’s lack of recognition and “adequate” treatment of psychological illness. The call to “screen-detect-treat” patients with mental illness is relentless, with primary care increasingly being asked to implement mass screening for depression, with questionable evidence that this is a rational approach(8, 9). Beyond the issues of over-identifying depression, the potential risks of labeling are completely uninvestigated. From a treatment standpoint, a single-minded approach that emphasizes biological pathways alone ignores the large body of evidence for the importance of stressors and life-events in psychological distress(10). This is quite unique to mental health. No one would argue that reduction of exposure to inhaled irritants is irrelevant in asthma patients. Would it make sense to only rely on inhaled salmeterol and betamethasone? Yet, this is the drug centered, illness centered approach primary care is called to adopt. Where to from here? The situation for primary care in the US, and perhaps in other countries does appear bleak. Callahan and Berrios argue that primary care bears some of the responsibility for being willing to accept a “thousand roles.”(7) However, they also argue that patients with psychological symptoms are for primary care the “canary in the coalmine,” calling us to an awareness that we as primary care physicians must take responsibility for reinventing ourselves. I believe a recovery of patient-centered medicine as expressed by Michael and Enid Balint is essential to this reinvention. Even for those who fully ascribe to an illness-centered approach, there will always be patients who do not respond to illness-centered medicine. Whether it be a depressed patient who may be numbed to the sorrow of a life unfulfilled but still unable to function or an asthmatic too anxious to cease wheezing, we can only be effective by allowing ourselves to be open to the whole picture that patients offer us. Medical training strives to teach us to resist this openness to patients. Touching emotion is not only distracting, it could be dangerous for patients and ourselves. Certainly there is an element of truth in this. Without training, nearly everything we do in medicine has the potential for harm. Yet this is no reason to recoil or resist, rather we must shout loudly this is the reason one must train to effectively and safely be open to patients. No other educational process does this as well as Balint work. As expressed by Lichtenstein and Lustig: When a doctor encounters a set of inconclusive or conflicting set of physical symptoms, it makes sense to delay resolution (diagnosis) and do what is necessary in terms of laboratory tests, consulting the literature, or consulting colleagues in order to correctly treat the patient. When the same thing happens in the doctor-patient relationship…a Balint group can help the doctor Paper presented at The First Dutch Balint Conference, Oegstgeest, Netherlands, Oct 17th 2008. bear uncertainty and explore possible understandings. In contrast to didactics or reading, the Balint process reaches past the rational system to influence intuitive functioning. It does so by engaging the intuitive system through encouraging nonjudgmental speculation, while at the same time monitoring rationally by juxtaposing the doctor and patient’s views.(11) Times are indeed challenging. There is an urgent need for boldness. The evidence is there in healthy patients and healthy doctors. Patient-entered medicine and patient-centered primary care is waiting to be recovered. We who have the tools bear the responsibility for its recover. Emanuel E, Fuchs V. The Perfect Storm of Overutilization. JAMA. 2008 Jun Ebell MH. Future Salary and US Residency Fill Rate Revisited. JAMA: The Journal of the American Medical Association. 2008 Sep 10;300(10):1131. Number of persons who consulted a physician, 1997 and 2002. American family Wagner E, Austin B, Von Korff M. Organizing care for patients with chronic illness. The Milbank quarterly. 1996 Jan 1;74(4):511-44. Berenson RA, Hammons T, Gans DN, Zuckerman S, Merrell K, Underwood WS, et al. A house is not a home: keeping patients at the center of practice redesign. Health affairs (Project Hope). 2008 Jan 1;27(5):1219-30. Balint E. The possibilities of patient-centered medicine. The Journal of the Royal College of General Practitioners. 1969 May 1;17(82):269-76. Callahan CM, Berrios GE. Reinventing depression : a history of the treatment of depression in primary care, 1940-2004. Oxford ; New York: Oxford University Press; 2005. Nease DE, Aikens JE, Schwenk TL. Mental health disorders and their descriptive criteria in primary care: clarifying or confounding? Prim Care Companion J Clin Psychiatry. 2005;7(3):89-90. Nease DE, Jr., Maloin JM. Depression screening: a practical strategy. J Fam Pract. Coyne JC, Gallo SM, Klinkman MS, Calarco MM. Effects of recent and past major depression and distress on self- concept and coping. J Abnorm Psychol. 1998;107(1):86-96. Lichtenstein A. Integrating intuition and reasoning--how Balint groups can help medical decision making. Australian family physician. 2006 Dec 1;35(12):987-9.

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