Lessons From Orthopedic Surgeons

I sprained my ankle last Friday.  It was a curious experience because it is probably the first time I sprained an ankle in about 40 years.  I just rolled it over coming off the bottom step of a stairway and then did the same thing at home the same day.  Some pain but not bad.  I was immediately able to walk on it and bear full weight on it.  Over the next week it was a waxing and waning course.  Still able to walk.  Most of the stiffness and pain in the morning.  About every other day I took a tablet of the naproxen in the morning and that seemed to alleviate the pain by evening.  I went to work, at a job where I typically put in at least 10,000 steps per day on a fairly large campus.  A week later it was unchanged, still painful at times and swollen.  I thought I needed an x-ray to rule out a fracture.  The question is - where to go?  Emergency departments in my experience are the absolute slowest.  I could also imagine the eye rolling when I tell them the injury is a week old.  I could go to the local urgent care center, but they seem surprisingly ill equipped for most problems.  I was there a few years ago for bronchitis and they shot a chest x-ray that was overpenetrated and useless for seeing infiltrates.  I would not have  lot of confidence in their ability to shoot an ankle film with adequate technique to take an optimal look for fracture sites.  I could go to my primary care  clinic, but that takes phone time and half a day of PTO.  All I need to know - is there a fracture, do I need to see an orthopedic surgeon, and what do I do to take care of it.  The last time I had an orthopedic problem and needed to get a splint, my primary care clinic referred me to a pharmacy that had a lot of medical equipment.  They did not have much in onsite to help me.

Then I remembered seeing an ad for an orthopedic surgery specialty group.  They had a number of new city-wide clinics.  One of their features was an acute injury walk in clinic.  No appointment was necessary.  I had nothing to lose.

The clinic lobby looked like one that you might see in a luxury hotel.  There were a bank of receptionists there to get the process going.  After about 10 minutes of paperwork, I was taken to an exam room by an RN who examined the ankle and took additional history.  A minute later, I was off to x-ray for three views of the ankle.  A minute after I got back to the room, I was examined by a physician's assistant who immediately let me know that there was no sign of a fracture.  She took additional history, and did a more extensive examination of the foot and ankle.  he showed me very good resolution views of the ankle on her flat screen computer monitor.  She Ace wrapped the ankle gave me some care advice, two extra Ace wraps and sent me on my way.  The total time of the visit was 30 minutes - 20 minutes if you don't count the time I was filling out the forms.  It was all very focused and very efficient.

According to the American Academy of Orthopaedic Surgeons, in 2014 here were 28,047 orthopedic surgeons in the United States.  The American Association of Medical Colleges estimates 49,079 psychiatrists for  comparable time period (2013) in the US.  Various sources including the American Psychiatric Association release stories about the shortage of psychiatrists.  I have not ever heard of a shortage of orthopedic surgeons.  But what does that mean?  Shortages are often measured by the ease of getting an appointment.  In some cases managed care organizations are quick to point this out possibly because many psychiatrists have fled both their work environments and compensation schemes.  The collaborative care models (there are several) are a work around in that patients can continue to go to their primary care clinics where there is a psychiatrist working behind the scenes - assuring that their medication therapy is rational and that their rating scale scores are trending in the right direction.  As far as I can tell, the vast majority of patients in collaborative care will never see a psychiatrist.  Problem solved right?    

Nobody seems to be applying the model I just experienced in this very focused and efficient orthopedic clinic.  The principles that I directly observed are:

1.  Not everybody needs to see a psychiatrist - The criteria for seeing a psychiatrist are very subjective based almost entirely on what the patient or the psychiatrist wants.  Many private practice psychiatrists want a set period of time to do an initial evaluation and follow ups.  Employed psychiatrists have to use whatever time they are allotted by the masterminds who are managing their productivity.  What is the lesson from the orthopods?  Triage the patient and see only the patients with the most complex problems.  As long as I did not have a complex ankle fracture, I could see a PA-C and get perfectly fine care.

2.  The resulting structure of the clinic benefits from that hierarchy of complexity - There were numerous exam rooms with teams of PA-Cs, nurses, and x-ray techs, screening high numbers of walk ins and treating them rapidly and efficiently.  The orthopods were on site doing ambulatory surgery and following up with complex post-op and non-operative patients.  There were also a number of physicians on site who were not surgeons but who focused on the medical treatment of sports injuries and spinal problems.  This has immediate applicability for psychiatry.  The procedures in psychiatry that create bottlenecks are electroconvulsive therapy and more recently ketamine infusions and transcranial magnetic stimulation (TMS).  Shifting psychiatrists away from more routine problems would immediately create greater capacity within systems to offer that higher level of care and it could be delivered in an ambulatory setting.  It could potentially provide needed treatment to thousands of people with treatment resistant problems who do not have easy access to a more intensive level of care.

3.  The culture of the orthopedic clinic was the care of the orthopedic patient, greatly enhancing the efficiency and focus of that process.  Orthopods don't provide collaborative care in primary care clinics and there is no broad initiative to get them there. Specialization has its benefits and in my experience all of the clinic personnel being focused on orthopedic problems was a plus.

4.  The orthopedic clinic had certain expectations of social behavior - it was not explicit but you needed insurance or an ability to pay.  Everyone was well behaved and nobody there was agitated or angry.  That may sound elitist, but for many mental health and addiction clinics there seems like an expectation that any behavior is tolerated and if the staff has to expend considerable time and effort to deal with the complex problem of aggression or agitated and otherwise inappropriate social behavior - they should also be prepared to provide those hours of care for free.

5.  The orthopedic clinic was providing care that has traditionally been done in hospitals and they were quick to point out the differences - complex care being delivered in a setting in  comfortable non-hospital surroundings with staffing ratio high enough to provide the level of care that people expect.  Managed care hospitals and clinics often try to manage expectations by interviewing protocols prior to giving that patient a satisfaction survey.  The approach used in this clinic is to redesign the clinic and service delivery first and then see what happens on the surveys.

6.  The orthopedic clinic has state-of-the-art equipment - No x-ray machines from the 1980s.  I saw high resolution images a few minutes after they were taken on a computer monitor in an exam room.  The contrast was excellent.

I know that a lot of physicians reading this are thinking that I have lost it.  Orthopedic surgery is a much more well compensated and well defined field than psychiatry.  How would a group of psychiatrists attempting this model be able to pull it off financially?  The biggest risk of course is managed care companies shifting most if not all financial risk to the clinic and poor reimbursement from public payers.  In my opinion, a lot of that is because of the usual biases against psychiatric care, but it is also due to the lack of negotiating savvy on the part of psychiatric clinics.  There is also a well known bias by managed care companies to get rid of psychiatric services or ration them either out of existence or to the point that any psychiatrist working for them is assured of providing a lot of work for free.  A good place to start would be to study models like this one or radiology or anesthesiology groups and figure out what percentage of their customary fees do they negotiate for in contracting arrangements.  Without that knowledge - you can't keep your doors open unless you adopt a straight fee-for-service arrangement with cash paying customers.  It has been demonstrated time and time again that managed care companies shut down psychiatric clinics and reimburse so poorly that most practitioners cannot accept their patients.

There are a number of arguments out there - many by other psychiatrists on whether a clinic like the one I suggest should exist.  The standard argument is that it will skim off the "worried well" and not treat serious psychiatric problems.  My experience in numerous clinics and hospital settings would suggest otherwise.  There are many people with acute crisis situations or stress responses who end up in the emergency department where they get admitted on emergency involuntary holds.  They may go to a primary care clinic where they are referred to the ED if they are perceived as having suicidal ideation or just put on antidepressants.  The majority of these patients do not have a serious psychiatric disorder and need a crisis care center where they can get active treatment.  In this case the "worried well" have been mishandled for decades.  Another resource that is needed is a safe place to treat hypomanic or manic patients who can't function at work or at home.  None of these folks likes to be housed in a hospital active day treatment with some temporary housing may be possible in a large well resourced psychiatric clinic.

Psychiatry has been thoroughly fragmented by by managed care systems and governments.  A large clinic like the orthopedic clinic I described, but focused on psychiatric services could potentially pull together many of the resources needed for comprehensive care and greatly improve quality.  Anything moving psychiatric practice away from brief sessions focused on managing polypharmacy toward providing comprehensive services again would do the same.


George Dawson, MD, DFAPA



Attributions:

1.  Left ankle is my actual ankle x-ray.

Nice Survey - Wrong Conclusion

There is a survey study of ease of getting and appointment with a psychiatrist in this month's Psychiatric Services.  The researchers called psychiatrists offices in three major cities in order to get an appointment.  They wanted to assess the degree of difficulty and whether or not payer source would be a factor.  Of the total calls only about 25% resulted in an appointment.  The reasons are listed in two tables in the article that is available on line.   Interestingly  there was no big difference  between private pay payer sources and insurance or Medicare in terms of getting appointments.  Given the movement of psychiatrists out of employee systems and Medicare based systems that was surprising and suggests to me a possible sampling flaw in the study or an artifact of the low return rate.  The flaw could be that the researchers looked at a Blue Cross Blue Shield (BCBS) web site and called lists of in-network providers in Boston, Houston, and Chicago.  The authors in this case do a reasonable job analyzing their limited data.  In their discussion of possible solutions they fall short of possible solutions.

In this case a key assumption is that the inability to set up appointments with psychiatrists implies there is limited access and this in turn means a shortage of psychiatrists.  We are hearing this argument at a time when managed care organizations like BCBS are basically saying that patients can receive psychiatric care in a primary care clinic.   In fact, BCBS was one of the early adopters of the PHQ-9 based Diamond project, where PHQ-9 scores formed the basis of a depression diagnosis in primary care clinics and the focus was optimizing antidepressant prescriptions based on those scores.  Where does an appointment to see a psychiatrist fit in that type of care?  Does collaborative care mean collaboration with a psychiatrist for every 500 or 1,000 or 10,000 primary care patients with an elevated PHQ-9 score?  Are patients in systems of mass care likely to seek psychiatric consultation?  In many algorithms of similar integrated care, some systems are set up to avoid psychiatrists completely, including the psychiatrist who is doing the psychopharmacological consultation.   How would such a system of care bias patients against psychiatrists and would psychiatrists be more dependent on other referral sources? And most importantly, wouldn't we expect limited access to a group of psychiatrists designated as in-network providers for a managed care company?  This is after all what managed care companies do.  They provide disincentives for physicians to see patients.  Managed care is a rationing mechanism.  It does not surprise me at all that physicians operating in that environment are difficult to see.

The authors propose that there are a number of ways to get medical students interested in psychiatry and that this would potentially solve the problem.  I don't know how that would work if there are already psychiatrists out there who are either working too hard or not interested in seeing new patients or referrals.  There was also the issue of psychiatrists being listed with incorrect phone numbers in over 10% of the cases.  It would also be interesting to note if the psychiatrist contacted agreed that he or she was actually in the network of care being described.  Many psychiatrists have told me they were in networks or panels that they had never agreed to participate in.

As I have previously stated, I don't think it is a question of recruiting more people in to psychiatry.  That approach ignores the state of crisis that the field is in right now.  That crisis involves the government and managed care companies dictating what psychiatric care is.  It also involves the American Board of Medical Specialties dictating what they think psychiatrists need to do for ongoing professional education.  It involves professional organizations - both the American Psychiatric Association (APA) and the American Medical Association (AMA) abandoning their member practitioners for what appears to be short term political gain.  The first thing lost to the politicians and businessmen  has been the practice environment.  Being a physician is more and more like being an assembly line worker.  Physicians are accountable to managers with no medical knowledge and no professional standards.  All of these developments have clearly demoralized physicians.

Taking a look at one of the suggestions, an interesting one was the suggestion that exposure to psychodynamic therapy increases medical student choice of psychiatry as a speciality field.  There are a few problems with that theory that are consistent with the deterioration of the practice environment.  It is certainly unlikely that any trained psychiatrist would make their expected productivity numbers for employees by doing psychodynamic psychotherapy.  It is currently practiced strictly in private settings or as supplementary activity once the productivity expectations are met in other endeavors.  Some psychiatrists have a psychotherapy practice "on the side" of their main employment.  It is highly unlikely that hospital or clinic environments are psychodynamically informed settings anymore or that residents learn how to manage those problems.  Many of those environments are a set up for split treatment.  Using psychodynamic psychiatry to sell residency to medical students seems like an informed consent issue to me.   Sure we will train you in it and supervise you doing the therapy but good luck practicing it in the real world.  I could put together a program that medical students would flock to, but they would never be able to use what they learned in a dumbed down practice environment.

You cannot have a profession that allows itself to be defined by hack politicians and businessmen with their own for-profit agenda.  Unless organized medicine and psychiatry focuses on that basic element, everything else is rearranging chairs on the deck of the Titanic.  Successfully rationing care does not mean there is a shortage of doctors.  It may mean the doctors just find the cost of doing business with a particular insurance company so high that they would prefer to see fewer or no patients from that payer.

It is absolutely mind blowing to me that nobody else can see that.


George Dawson, MD, DFAPA

Ref:

Monica Malowney, Sarah Keltz, Daniel Fischer, J. Wesley Boyd; Availability of Outpatient Care From Psychiatrists: A Simulated-Patient Study in Three U.S. Cities. Psychiatric Services. 2014 Oct (early online release).