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→ This post was written by Dr. Alan Brown, MD from the UMass Chan Medical School Department of Psychiatry
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I have thoroughly enjoyed my work in Family Medicine, particularly my stint as an embedded psychiatric consultant at the Barre Family Health Center. I am physically there twice a month - one day for consultations and another half day with psychiatric residents, supervising them in integrated care psychiatry.
We offer a genuine patient centered medical home and as a team follow patients with severe psychiatric disorders who lack adequate access to reasonable quality care—I could not ask for a better group of consultees and collaborators. Electronically and mentally, I am there every day, fielding e-consultations and helping with care coordination or thinking about program development and support or prepping a lecture or arranging an elective for FM residents. I feel appreciated by my colleagues and patients there, although I’m not sure folks fully understand what I do (heck, not sure I do either), so I wanted to try to explain a bit more what I am up to when I sit down with a patient.
When I sit down to interview patient I am mostly trying to juggle three balls of interest:
- Collecting information so I can offer recommendations about what I think should happen next, short and immediate term
- Understanding others’ perspectives of the problem, particularly the patient’s
- Managing the interactions between myself and the patient and steering us toward a positive working relationship.
When I am done, I should have a tentative idea of how to proceed that I think will help this particular person working with this particular family and care team, given the patient’s so-called illnesses and recommended treatments as described in the clinical literature and informed by my own experience. My work is not particularly complicated (a relatively limited number of diagnoses and ICD 10 codes and a limited therapeutic armamentarium of medications and therapies to master), but it is complex (these three balls of interest can interact in unpredictable and variable ways to which I need to be attuned and responsive throughout the interview).
When attempting to provide affordable healthcare, proponents of the high-quality psychiatric assessment must consider the sheer prevalence of severe psychiatric illnesses afflicting about ten percent of the population.
"My most promising experience"
Here my work with Family Medicine has been perhaps most promising—together working as a team with primary care providers, psychologists, social workers, nurses and care managers, we can assess and optimize care of the complicated population we serve and the complex individuals we treat.
The psychiatric consultation no longer ends with a lengthy report of a long list of possibilities and recommendations of limited relevance—it provides a working document, bolstered by dialogue with the team; it is a beginning of an ongoing, supportive role for myself in collaboration with the team and the patient; it is the basis for further re-consultation when care is stalled or failing; it is part of an ongoing relationship between myself and my diverse group of colleagues and residents who share a common commitment to our patients, who like all individual human beings, seem to resist standardization and want to be understood in their own terms.
While I hope our patients are getting better thanks to the work we are doing, at least I can reliably report that I am. As a doctor, I have always most enjoyed re-establishing meaningful ties and connections to persons isolated and deemed “difficult” by the dint of their troubled pasts with other humans or psychiatric illness. As a younger clinician I wanted to be the heroic agent of therapeutic change and found myself working in all sorts of institutions that seemed to have lost their way—dilapidated state hospitals post de-institutionalization and prison hospitals under federal watch. Older now, I am not so choosy about where change comes from, just happy to witness it, to have a team and patients to share it with and to be in a clinic where it matters.
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About the Author:
Dr. Alan Brown, MD from the UMass Chan Medical School Department of Psychiatry. He is Vice-Chair for Adult Clinical Services, Professor of Psychiatry and an Attending Psychiatrist. You can read more about his research interest and academic background here.
