By Janet L. Hurley, MD
It’s taken a while for me to be ready to write about this. It is challenging as a physician to have things go wrong with a patient—badly wrong. Such situations are a major cause of physician burnout and job dissatisfaction. Some years ago I had such an event, and the effect was harrowing.
Suffice it to say we need more mental health resources in many Texas communities to provide needed services to patients and support to primary care physicians. As I speak to family physicians across the state, I learn the challenges my region experiences with insufficient mental health access are not unique. I am tired of patients being dismissed from mental health institutions back into the care of their primary care physician because there is no psychiatrist to see them for follow-up. I am tired of the insufficient payment structure that makes psychiatrists move to cash-only arrangements, limiting a patient’s ability to afford their care. I’m tired of having to treat refractory depression, advanced bipolar, and psychosis, simply because there are limited psychiatrists to do it. This simply needs to change.
My patient had challenges at home, which made it difficult for them to get their mental health condition to remission. I referred this patient to psychiatry, yet there was no one who took their insurance. There was a change in the home environment that helped a great deal, yet the patient returned back to the dysfunctional situation they were in with disastrous results. When tensions arose, a family member died, and my patient was arrested. The stress eventually killed my patient, too.
I went over that case in my mind time and time again. The effect kept me up at night. There were legal issues surrounding the case and lawyers were hired. The standard legal mantra is “don’t talk to anyone about anything” and that is good legal advice. Yet this meant that I could not talk out my problems with friends or trusted colleagues, use this case to foster changes in our health system, or share details in a column like this. Yet this case clearly changed me. It was the most disparaging moment in my clinical career.
There simply are not enough psychiatrists to take care of mental health needs in our communities. In my region, the local Mental Health and Mental Retardation facility usually has a three month wait, and patients in behavioral crises cannot wait three months to get help. Many of my patients cannot afford to do cash-only arrangements required by most local psychiatrists, and even the cash-only psychiatrists in my area have a several months wait. Those that take insurance sometimes have restrictive criteria about what conditions they will and will not see. And sometimes there are other barriers.
Most of the time, it is not possible for patients to make long trips to the neighboring big city for psychiatric care. Thus primary care physicians are left to manage these patients themselves as best they can, even if the patient has dementia and bad mood swings with psychosis, even if they just got discharged from an inpatient behavioral health hospital with suicidal depression, and even if they have severe depression and anxiety with uncontrolled eating disorders on multiple medications. These are real patients, sent to me through the years to manage. Psychiatrists might tell me that I should not be taking care of such patients outside of my typical family medicine scope, yet I have limited other choices. Some care is better than no care. Yet as the first case in this article reminds, sometimes people do bad things or die because of their mental health condition, even with the best care I can provide.
I still remember the panicked text I got from a friend of mine whose teenage son had just been discharged from an inpatient psychiatric facility, yet was still hearing voices telling him to kill himself. He had expended all his inpatient psychiatric payable days. The father was told by office staff at both pediatric psychiatry practices in town that they had a three month wait, and his son’s primary care physician would not treat him. Out of desperation he asked for my advice. Out of desperation I saw his son. That day I diagnosed his son’s bipolar disorder, stopped his antidepressant, started a mood stabilizer and an antipsychotic, and essentially begged a pediatric psychiatrist in town to see him within a few weeks. Was I practicing outside of my scope? As a family physician am I supposed to be managing psychotic, suicidal, pediatric bipolar disorder? Did I open myself up to medicolegal risk?
This teenager is now a grown man in his 20s with a life full of promise. His father would say I saved his son’s life. I would say this desperate situation should have never happened in the first place and points to a pathetic decay of behavioral health infrastructure which put this young man’s life at risk. That needs to change.
Telepsychiatry is one option, yet beyond consultation, every family physician needs to have access to a psychiatrist from whom they can get advice. Larger health systems should foster such relationships and provide this support to their primary care physicians. Private physicians can get this support free of charge via the Project Echo platform. You can learn more about this at the following web address: https://echo.unm.edu.
It is well known that patients with undertreated mental health disorders are costlier to insurance payers. Such patients are more likely to have frequent ER visits, be non-adherent to management for chronic conditions, and will present with more psychosomatic complaints prompting medical work-up. I implore insurance payers to be more creative with payment strategies for mental health conditions to encourage more availability of services for this critical need.
Acknowledging that this is a significant source of frustration for Texas family physicians, TAFP will continue to negotiate with payers and advocate for these needs in the Texas Legislature. Yet many of these solutions will need to be found locally within our individual communities, and TAFP will continue to look for ways to provide quality education and ongoing support to our members.
It’s too late for the first patient mentioned in this article. Would their outcome have been different if they had seen a psychiatrist? We’ll never know. Yet leaving primary care physicians without necessary psychiatric support is a source for physician burnout that our profession cannot shoulder. I can attest that my shoulders were heavy with that emotional burden for more than a year.
Our patients deserve better, and so do we.