Shared(?) Care

In the previous post, I highlighted the deliberate absence of performance measures for our mental health system and why that is.

I gave an example showing that when people in the system work in an information vacuum, it becomes impossible to prioritize or assess the impact of their efforts. In this post, you’ll see another example, more directly related to patients’ experiences of the health system: shared care.

But first, pop quiz! What is shared care in mental health?

  1. more than one treatment provider is involved with the patient
  2. a family physician refers the patient to a specialist for advice
  3. treatment providers talk to each other about a case
  4. different providers divide up the work so each has their own piece
  5. bouncing patients between treatment providers so they never see the same person twice
  6. a meaningless marketing label that means whatever you want
  7. a solid, meaningful treatment philosophy that is universally diluted and abused
  8. whatever receives funding from the shared care committee

Theory

“Shared care” is another of those aspirational motherhood terms like “patient-centered” that are hard to disagree with. In the psychiatric context, it means that family physicians, psychiatrists, and potentially other professionals work together to provide the best care for the patient. Each contributes as part of a unified, cohesive treatment plan.

Notice words like “together,” “unified,” and “cohesive.” Shared care is all about effective collaboration.

Collaboration requires many things to be shared: common goals, awareness of others’ needs, roles, actions, and responsibilities, the context in which people work. Lots of feedback and listening to each other.

As it happens, my previous work was all about facilitating effective collaboration and how technology can affect that, positively or negatively. It’s a highly multidisciplinary field, bridging technology, psychology, sociology, management, and other specialties. So yes, this world of Zoom we’re in now is right up my alley. For two decades, I did cutting-edge R&D, published extensively, and ran companies built around collaboration practices and technologies.

How it could work

There’s no one model of shared mental health care. But what would shared care, say between a family physician and a psychiatrist, look like? You’d expect to see several practices like these:

  • understand the skills and limitations each brings to the case
  • understand each others’ needs, work context, challenges, and resources
  • work together to create a treatment plan that meets everyone’s needs
  • psychiatrist and family physician at times jointly meet with patient
  • each professional learns from the other
  • shared understanding of patient’s goals and progress
  • assessment and appreciation of what individual contributions bring, how effective they are, and which parts can be improved
  • ongoing two-way communication over time regarding the case
  • back-and-forth discussions, questions and answers, etc.
  • awareness of what each participant contributes to the case, as well as gaps in the overall treatment

If done well, patients benefit from consistent and improved care. Practitioners develop increased skills by learning from each other and better appreciate how their contribution fits into the overall system. Scarce resources can be used more effectively.

Practice

If there’s virtually no feedback, interaction, or awareness between collaborators, is it really shared care?

Consider a traditional referral-consultation model:

  • family doc sends in referral
  • psychiatrist sees patient once for consultation
  • psychiatrist sends written report to family doc
  • family doc resumes care based on psychiatrist’s suggestions

Technically, both the psychiatrist and the family doc are involved in the treatment. There is some information going back and forth. But it’s pretty thin as far as collaboration goes.

It’s not one or the other, of course. Shared care is a continuum. The family doctor might call the psychiatrist later with questions or seek clarification. Other interventions may be discussed. The psychiatrist might see the patient again, send another report or make further suggestions. And so on.

Psychiatrists may be trained to do a full assessment in under an hour, but that doesn’t mean it will be complete and accurate. That may be because it’s a particularly complicated case, or the patient may not (for many reasons) be able to fully understand or give accurate answers to all questions.

Most psychiatrists who see a patient multiple times find their understanding of the patient evolves over time, as do their recommendations. Seeing someone for a one-off visit can result in significant simplifications, omissions, and errors.

Measuring success

For straightforward cases, a one-off traditional consultation may be all that is required. The report gives the family doc what they need to better manage the patient, and the patient gets better. Everyone is happy.

Notice that even here, success is judged from the perspective of the patient, as well as the family doc (in terms of having gotten what they needed from the psychiatrist). The psychiatrist is providing a service to the family doc.

But how does the psychiatrist know if the service they’ve provided is useful?

If there’s no further communication after sending the report, they don’t. They don’t know whether the patient got better or not. They don’t know if their recommendations were helpful, tried, or even made sense. Without feedback, they don’t know what value, if any, their participation added.

At most, they might get the hint when people stop referring to them. If there are other options.

Importantly, the psychiatrist learned nothing more about the needs of the family doc, the constraints they work under, or how they might provide better assistance in the future.

Pitfalls

Unless that feedback is provided by some other means, they’re operating in an information vacuum. And as we know, the overall system is in no hurry to provide any concrete information about the quality of service.

What could possibly go wrong?

  • If a psychiatrist does a shitty assessment or makes poor recommendations, they’ll never know about it. They think they’re doing great and have no reason to change what they’re doing.
  • If their recommendations don’t work, aren’t useful, or can’t be followed by a family physician, they may never know. Again, future improvement isn’t likely.
  • The psychiatrist might assume that family docs have the time, skills, resources, and willingness to follow up with treatment recommendations. There’s little opportunity to learn about the constraints family docs work under and what they need.
  • Most psychiatric treatments involve trial and error, and without follow-up, may mean re-referral. Which can involve lengthy delays. And often, the patient starts from scratch with another psychiatrist.
  • Patients may receive inefficient, ineffective, disjointed, sub-par care. Especially if their illness is at all complex.

In other words, one psychiatrist may be doing the most horrific job in the world. Another might be doing the best job in the world. It’s possible that neither would ever know.

And nobody else in the system sees there is a problem or what needs to improve.

Hidden problems

These problems are hidden, and you need to go digging to find them.

Nobody measures or reports on these things, so how do we know these problems occur? We hear lots of stories from patients. We ask and then listen to family doctors to appreciate their needs and struggles.

Many people find ways to get feedback, engage in more collaborative activities, and learn from patients and colleagues. But it’s a deliberate effort. Not everyone bothers.

Some psychiatrists pretty much do only one-size-fits-all, one-time assessments. If you asked them, how many would say their advice isn’t helpful or sufficient for family doctors to manage cases? Some may be surprised at the question, not having considered how their assessments are used at all. Family doctors see it differently.

How widespread are these problems? They “seem” pretty common, but that’s largely anecdotal and based on our very narrow viewport on the system. Other people have vastly different perspectives.

There’s really no way to know the frequency and severity of these problems. Which is really the issue.

Escalation

The busier things are, the worse it gets. Waitlists are longer. Time to see patients shrinks. Services are more tightly restricted. The distance between family docs and psychiatrists grows. Opportunities for feedback and collaboration wither.

For many, job satisfaction suffers as they find it more difficult to provide the type of care they want, especially for more complex patients. Burnout increases. More people leave. Others get more jaded. Some just keep their head down and continue on, oblivious.

In computing, there’s a phenomenon called “thrashing.” As a system gets busier, more and more time is spent on busy work (housekeeping, management, repetitive and redundant tasks which have little impact overall). This leads to less and less time for productive work to achieve goals. An apt metaphor here?

Everyone lives more and more in their own echo chamber. Viewpoints narrow further, and system thinking decreases. “The way we do things around here,” good or bad, becomes increasingly entrenched.

Toxicity

Isolation breeds misconceptions and contempt.

Psychiatrists see themselves more and more stretched. The scarcity of specialist time feels more pronounced, justifying ever-more abbreviated patient involvement. Ongoing treatment of patients and follow-up care is a luxury they can’t afford.

Resource-wise, it just makes sense to devolve follow-up care to family doctors who have so much more time to spend with patients. Except, of course, they really don’t. Family docs are stretched beyond belief and have far less time. But the family doctor crisis isn’t in the face of specialists each and every day.

Good mental health care takes time that doesn’t fit into increasingly abbreviated family medicine appointments. Family docs who devote that time do so at the expense of their other patients or their own health. Most do what they can, even if it’s not enough. Some do virtually no mental health care. And what about the growing numbers without access to any family doctor?

System access problems? Not a thing. Any family doctor can get a consultation by referring their patients through mental health intake. Crisis? USTAT is there. If only.

Yes, psychiatrists may be working flat out and focused on the task at hand. But if they’re too entrenched in their bubble, they may not be fully cognizant that the one hour they spend follows many months of rejections, waiting, and other delays.

Without evidence to the contrary, some people (who should know better) are deluded into thinking that the system on paper reflects reality.

Misconceptions flow in more than one direction. Frustrated family doctors may feel psychiatrists don’t care or are completely oblivious to the needs and realities of family practice. Private-practice psychiatrists who follow patients? Obviously, a ludicrous and inefficient drag on resources, who cherry-pick the “weepy well” patients who don’t need to be seen at all. The family doctors can see them. That’s why we do shared care here.

Reckoning

Without rich feedback and collaboration, shared care is an empty buzzword. A myopic fantasy.

It justifies silos, narrows thinking, reinforces the status quo, and abdicates responsibility. It stifles innovation and suffocates empathy.

It reassures us that we’re each playing the part we should be.

It’s not our fault.

Any system this large, this complex, and this important needs to deeply incorporate shared understanding, awareness, collaboration, feedback, and empathy. Only then can true shared care follow.

Individual efforts are important but only go so far. Systemic solutions are at odds with the perverse incentives at the core of the system.

There’s no easy path forward.

Related: see all Victoria posts here

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