xxAACP Newsletter, Volume 11,
Number 1, Winter 1997
Child Psychiatry in the CMHC: A Consultation
Dear Charley:
I am supervising a child fellow for her community mental health experience. The fellows spend six hours at the CMHC a week. At this time it is divided: 1 hour on a new eval; .5 hour on a team meeting; four 30 minute follow ups; .5 hour supervision (with a faculty member who is an adult psychiatrist); 1 hour flexible (for a patient or paper work). Only 2nd year fellows are at the CMHC, and they stay for one year. When they come in, they are basically booked up for the next two months. So, if, after an evaluation, they start someone on meds, there's often no appropriate follow up time slot available.
Of note is that the team meeting does not include the primary therapists for all the patients the fellow might see that day. I have encouraged the fellow to establish a paper relationship with all the primaries, leaving notes encouraging them to drop a note to the fellow with specific questions when they refer a patient for med eval, or to drop notes regarding how the patient is progressing (or not) when the patient is due for follow up visits. And since it turns out that there is a nurse in the CMHC, I have encouraged the fellow to use her as a physician extender, making follow up calls regarding new meds, or to instruct the patient/family to call and check in with the nurse. I've also stated that the primary therapist can be used in this way somewhat as well, depending on how comfortable the therapist is with meds.
I think a one hour eval is a little nuts. I'm trying to help the fellow
focus her initial interview so that it can be more effectively
accomplished in that time span. Short of having a referral written out
from the primary, do you have any recommendations? Any thought on making
documentation time efficient? I've told her that for follow up visits
(that are actually initial visits for her) to do some initial schmoozing
and then ask the patient/family: 1) what the meds are for; 2) are the meds
working; 3) are there side effects and then go for more history, to make
the .5 hour more effective. Do you have any other recommendations on the
matter? Thanks, C.A.M.
Dear C.A.M.:
Let me try to address all your issues. I have dealt with them all. I suppose that the first question I would have for you is whether you and your residents or the power structure of your University have any hope of changing the system. It clearly needs changing. If so, then the educational experience should be designed, in part, as an exercise in systems change. If that is unrealistic, help residents see for themselves what the real world looks like in all its inadequacies and help them conceptualize what changes they would make if they could, as well as doing the best they can with what they have. Create an agenda for systems change and use the resident as an agent of advocacy with the power structurs of the CMHC system and of your university system, the county or the state. I would model for the resident how to responsibly raise a little hell.
Now to some specifics: I think that a one hour medication evaluation is unfortunately common and given funding constraints actually necesary. But it can be done only if there is adequate contact between the primary clinician (therapist or clinical case manager) and the psychiatrist. The resident can be a team member blended into a much wider evaluation, participating in the diagnostic and treatment formulation while sitting in on staffing discussions with the team. Then the med/psych evaluation as a double check in an hour is usually fine. My rule is to include the case manager in the evaluation with me as one who can facilitate my rapidly forming a relationship with the kid and his family. Another necessity for competent work for a new evaluation includes plenty of time to talk to parents.
For patients one is familiar with, one half hour med checks are fine if they are done after updating oneself with the treatment team. Programs should allow the psychiatrist to have some hangout time with the kids in other settings as well. I think that makes for better med follow-up and can make the formal check in time even briefer. There is no way agencies can expect psychiatrists to do their work with any degree of compentence if they don't get included as part of the team.
I think that as a resident takes on a new caseload they need more than .5 hour to be introduced to a case. I think your format of getting crucial drug information first is efficient but it is not a great way to introduce yourself to a kid. Some kids and families just won't relate to such treatment and will discount the psychiatrist as hurried, disinterested and not to be trusted. Real trust is essential if med compliance has a hope. An hour is needed for new cases in addition to time for thorough chart review and case discussion. My strong belief is that paper relationships just don't work. Nuances just don't get communicated. Primary clinicians also have to know the psychiatrist if they are to trust them as a co-professional. The easiest thing in the world is for mental health workers to discount a psychiatrist they don't know and subtly render them a fool when they don't like or trust them.
The issue of growing caseloads is a big issue. I think that clinical quality cannot ever be allowed to be compromised because of time constraints. I would leave an unscheduled .5 hour of crisis time or special and unusual professional communication time weekly. If a new resident inherits 12 old cases for instance, I would make it clear that in that year they will take on only 8 more regular med patients, at least until someone drops out.
In the situation you describe the resident getting only .5 hour of team time and .5 hour of supervision from an adult psychiatrist (!!!). I assume that you're the personal remedy for the adult psychiatrist, but to me, that type of a supervisory arrangement is substandard. I would feel much better about the whole thing is an extra hour was devoted to team time; either team meetings or 1:1 meetings with the relevant case managers.
The one good thing about what you told me was that the program has a nurse. I totally agree with the basic idea of nurses as physician extenders except I think it is a bit more politically correct to say "team members." I also agree that this role should be extended actively to the case manager as well. It should be the psychiatrist's consultative responsiblity to educate the staff as to what is important for him or her to know about in the treatment which has relevance to the medication work.
I realize that what I had described is defining a standard which is obvious to us but often out of reach in a center. If we must work in a system which cannot afford such a standard, I am most comfortable if everyone agrees that times are tough and resources are inadequate, and if there is acknowledgement of this up and down the administration line. My belief is that a supervisor to a resident ought to be both a coach and a facilitator for the resident to seek change and also a direct participant as a power person allied with the resident urging change. I think that your boss should also be talking with the executive director as well. If money hamstrings you all, so be it, life is tought all over. Reality is reality but thought times spawn creativity too. What I would never do, however, is to model or teach complacency when things are rotten.
President
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