Why Become a Medical and Psychiatric Doctor?
Roger G. Kathol, M.D.
We live in a world divided. Patients with general medical illness are evaluated and treated in the physical health setting. Patients with psychiatric illness are assessed and treated in the mental health and substance use disorder (behavioral health--BH) setting. Payment in today's healthcare system for patients with the two types of illness is discrete and in many ways mutually exclusive.
As a result, little attention to physical illness is given to patients in the psychiatric setting, even by psychiatrists who have backgrounds and expertise with the potential to include it. Mental health professionals are paid to focus on BH issues. Physical health issues, should they exist, are diverted to the general medical setting, often despite the blatant physical condition contribution to the psychiatric presentation. If addressed, patient outcomes for both their general medical and psychiatric illness would predictably improve, however, medical issues are outside mental health's domain.
The reverse is true on the general medical side but with a twist. Seventy percent of patients with psychiatric illness are seen primarily, if not entirely, in the physical health setting. Seventy percent of them receive no intervention for their psychiatric condition. Of those treated, only twelve percent receive evidence-based care. Most primary care patients remain undiagnosed psychiatrically and/or refuse to enter the BH setting. Further, reimbursement business practices prevent access by primary and specialty medical physicians to geographically accessible BH practitioners. Psychiatrists and psychologists either do not receive adequate reimbursement for the services they give in the medical setting or the mechanics of seeing patients, such as prior authorization requirements and/or billing procedures, are so cumbersome that it is not worth the effort.
Primary and specialty medical physicians are financially accountable only for physical illness, BH clinicians only for mental and substance use disorders. This system is built on the assumption that the two do not overlap nor that they affect one another. Nothing could be further from the truth. Compelling evidence now shows that:
- More than 30% of patients with chronic physical disorders, such as diabetes, asthma, end stage renal disease, etc. have a concurrent psychiatric condition. An equal or greater number of patients with BH conditions either have a co-existing physical disorders or are seen more frequently for unexplained physical complaints in the physical health setting. Three quarters of those with serious mental illnesses have at least one chronic medical condition. Fifty percent have more than one.
- General medical and psychiatric illness outcomes for patients with comorbid illness are substantially worse when present in the same patient.
- Patients with BH conditions use twice the amount of health services when compared to those who do not. They also contribute more than any other studied group to disability costs for employers.
- 80% of health service use by those with BH disorders is for general medical, not psychiatric, assessment and intervention.
- The BH system does not communicate with the physical health system, therefore, there is no opportunity to coordinate care, improve clinical outcomes, and reverse financial burden in ineffectively treated patients.
During the past twenty years, the healthcare industry has become increasingly aware of the interaction of general medical and psychiatric illness described above. Movement to correct health system barriers to integrated physical and BH care is gaining momentum, thus, we are entering a phase of growth in which there is and will be an increasing demand for practitioners with the interest and expertise to address both medical and psychiatric needs in patients with comorbid illness. Combined internal medicine and psychiatric, family practice and psychiatry, and pediatric and adult/child psychiatry residencies are the premiere way to obtain the skills needed to do so.
Unlike even five years ago, opportunities for physicians with combined training have expanded dramatically. They include but are not limited to:
- Integrated, psychiatrically supported, medical outpatient clinics, e.g. collaborative care, soon to be paid through sustainable medical benefits;
- Integrated medical and psychiatric inpatient units (Complexity Intervention Units—CIUs), e.g. University of Iowa Hospitals, Portland Hospital (Maine), St. Mary's Hospital (Michigan), Massachusetts General Hospital, Duke University Hospital, others
- Integrated substance use disorder programs, e.g. primary care based buprenorphine clinics, primary care based alcohol screening and brief intervention (part of general medical clinics), primary care based physical health, alcohol detoxification, and rehabilitation programs
- Delirium prevention and treatment (often associated with CIUs)
- Physical health prevention and intervention programs for the chronic and persistent mentally ill, e.g. state and county mental hospitals, correctional facilities
- Specialty combined physical and BH treatment programs, e.g. eating disorders, oncology programs, end stage renal disease programs
- Integrated physical and BH administration, policy making
Up to this point, we have discussed practical reasons to consider becoming a physician with medical and psychiatric training but have neglected to talk about the patients suffering the ravages of concurrent physical and mental illness seen by those with combined training on a daily basis. Without a question, these are some of the most interesting, challenging, and demanding patients seen in the medical system. They are also among the most rewarding. Having the skills to reverse the downward spiral of patients who have failed treatment in several other areas within the health care system, leaves the jointly trained physician with a sense of accomplishment that few other practicing physicians experience.
Finally, integrated physical and mental health care is at its inception. Those who enter it at this time will have a wide variety of options at their fingertips. Many, in fact, will be able to create their own practice environment as interest in better ways to address the needs of complex, often high cost, patients gains importance. Those with combined training are at a particular advantage because they belong to two guilds, their medical guild (internal medicine, family practice, pediatric) and their psychiatry guild. As a member of both, it is possible to orchestrate cross-disciplinary opportunities that can only happen when ownership by cross-disciplinary stakeholders is needed for it to succeed.
Today's world is much different than the one that I entered in 1980 as an internist and psychiatrist. Not only did organizations not know what to do with me, they also did not see a vision for better care of patients in the future. Your world is different. While many still will not understand the value that those with combined training can bring, they now know that whatever it is, it has to be better for patients' health and economic viability than what is available in our fragmented delivery system. Thus, as you enter, create your own vision of value in your area of practice interest and pursue it with passion.