by Andrew Rudo, M.D., Medical Director, Green Spring of Maryland
[November 1995; Vol. 22 No. 5]
Recently in these pages, attention was focused on the very important role psychiatrists need to continue playing and expanding in relation to primary care physicians (PCPs). Green Spring Health Services, Inc., has from its inception, also felt that an important role for psychiatrists is to work closely with our internal medicine colleagues. This work has targeted three main areas: improving communication between treating physicians, educating PCPs in the diagnosis, treatment, and timely referral of psychiatric patients, and joining with PCPs in efforts to educate the HMO membership and general public on mental/substance abuse disorders. The major beneficiary of these efforts is the patient, who stands to gain from a primary care physician who is better educated on the diagnosis and treatment of mental and substance abuse disorders and also more familiar with when to refer for psychiatric consultation. The patient also benefits from the emphasis on frequent communication between physicians when a psychiatrist is involved in the treatment. Also, the joint effort at public education mobilizes more resources focused on the goals of early case identification and greater utilization of treatment early in the course of an illness.
Green Spring psychiatrists provide psychiatric services for HMO members of Blue Cross/Blue Shield of Maryland's HMOs: CFS Health Group, Inc., Columbia Medical Plan, and Delmarva Health Plan. Each of these members is required to select a PCP who has the responsibility of coordinating that member's entire health care. The member also benefits from the clinical administrative structure of such an organization, which maintains a sophisticated quality improvement (QI) effort and a comprehensive variety of outreach and educational programs, all designed to continually improve the physical and mental health of the member.
To accomplish the goal of physician to physician communication, Green Spring psychiatrists are required to periodically communicate in writing to the PCP. We require a letter to be sent to the PCP after the initial psychiatric evaluation, after treatment termination, and at all “significant” points in between such as a change in psychotropics, psychiatric hospitalization, etc. Our letters are carefully designed to provide enough information to keep the PCP appropriately informed but also are designed to protect the confidentiality of the patient. Of course, telephone conversations direct from physician to physician supplement this written communication. Our QI Committee continually monitors compliance with these standards and gives physicians feedback on their performance.
As many of us are aware, most patients with mental and/or substance abuse disorders first present in the primary care setting. Many primary care physicians are skilled in diagnosing and treating some of these conditions. Recognizing this, we work closely with the PCPs to further their education in diagnosis, treatment, and when to refer. This occurs in many settings. We have launched a telephone information service for the PCP entitled “Dial A Psychiatrist” (a service designed to provide prompt telephone access to a board certified psychiatrist to give information to the PCP about differential diagnosis, treatment options, and when to refer). A group of three psychiatrists rotate on a daytime on-call schedule to be able to return the call within 10-20 minutes to a PCP who has a question about their patient. A recent call example was a PCP requesting specific information on detoxification methods from opioids. Our psychiatrist reviewed with her the alternatives such as the appropriate use of Clonidine, and that physician was then able to apply the information to her patient. Sometimes our psychiatrist will recognize that the PCP can begin or continue the treatment of the respective patients, and at other times, will recommend that they refer the patient to a psychiatrist.
Our close association with the HMOs has allowed us the opportunity to be part of Pharmacy & Therapeutics Committees. With this experience we recently created a one page fact sheet on diagnosing depression, appropriately initiating treatment, and clues of when to refer for psychiatric consultation. This was distributed to every PCP in that HMO for reference. Additionally, we contribute by providing educational presentations to the PCPs on various mental health and substance abuse topics. For example, we recently presented two programs for the PCPs on the Eastern Shore entitled “The Primary Care Physician’s Guide to Outpatient Detoxification.” Finally, we have sponsored a fourth year residency elective in managed care for University of Maryland psychiatry residents since 1989. The resident is exposed to the importance and value of this comprehensive coordination with the PCP. It is our impression that those residents have gained invaluable experience in viewing themselves as a medical specialist working within a medical team.
It is our belief that our patients have clearly benefited from this close connection with the PCPs. As with all medical specialties, our job is not only to treat those patients that appropriately seek out our services, but also to better educate primary care physicians on how to diagnose and treat appropriate cases and when to refer.