Viewing Our Integration with Primary Care from the Ground Level

Integrated care gets complicated on the ground level where people try to fulfill its grand promises. Primary care is in crisis, as any PCP will attest, and the behavioral healthcare field has more pressing demands than medical collaboration. Few in our field have cheerful stories of such collaboration, and all parties involved want, above all else, good and secure jobs.

We need to hear from people on the front lines, especially those in primary care. The voices of doctors entering practice are preferable to those departing, and so an article by two Harvard-based residents is ideal. They articulate why they are rejecting a career in primary care after years of training:

Yet when we finish our residencies on June 28, neither of us will be practicing traditional primary care. We are not alone in turning away from this field: Approximately 80% of internal medicine residents, including nearly two-thirds of those who specifically chose primary care tracks, do not plan to pursue careers in primary care.

While these residents bemoan the long hours, low compensation relative to other MDs, and sizeable administrative burden of primary care, they are more troubled by how clinical practice has evolved. They see the care of large groups of patients being assumed by other entities. For example, healthier young people increasingly turn to urgent care, digital care, and basic care in retail clinics.

They see team-based care for people with complex behavioral health needs as a positive emerging trend. Yet every improvement is not a step forward for PCPs. In terms of team-based care and a greater focus on the social determinants of health, they see a likely secondary role for PCPs emerging. Community health workers may be the more likely candidates for leading these new teams.

These residents see that many clinical trends will possibly lead to better care for key patient groups, but they fear that the forces impinging on primary care are making it an undesirable field. They may fairly abandon primary care then, but the institution is not about to disappear. For example, many European countries tout their better-funded primary care systems as driving superior clinical outcomes.

This is the ground level. This is the messiness we find when we engage in discussions of integration. This does not mean any collaboration must be delayed, but PCPs are surely distracted by many issues. It means that our proposals must not be too complex or impractical, and yet they must be transformative. Only big changes with big results are worth consideration for a field in crisis.

The interest in primary care from those in our field has many origins, but a general trend is that psychotherapists are being drawn into new clinical settings not simply to address behavioral health disorders. People without diagnosable disorders have come into focus. Behavioral problems in primary care are varied. Many do not meet DSM criteria but still have a significant impact on health.

We have long known about the destructive impact of comorbid depression and anxiety for patients with chronic medical conditions like diabetes or heart disease. It is also well-know that unhealthy behaviors are preventing many of these patients with chronic conditions from stabilizing. Their unhealthy lifestyle persists despite PCP recommendations, and it drives poor health and ever higher healthcare costs.

Primary care exposes clinicians to the early stages of behavioral health disorders, as well as to problems that are mundane but not benign. Many unremarkable traits produce health-damaging behaviors, non-compliance with a doctor’s advice, and other dysfunction. Therapists may find primary care concerns less complex than depression, less gratifying than personal growth, but still vital and challenging.

It should be noted that psychiatrists have good PCP collaboration models. However, their diagnostic foundation typically restricts them to medication management, and they rarely work in the primary care setting. Psychiatric models of collaboration seem to be effective, and yet they do not involve the complexity of clinical integration. It is more a consultative approach focused on coordinating all care.

Integration is a growing reality today inside both commercial and government-funded systems. A review by the APA found more than 500,000 patients in civilian systems and 3.4 million under the Department of Defense with access to this model of care. Are the innovators in these systems finding new skills are needed? New cross-training procedures? Perhaps just more time to learn?

There are good clinical reasons for care integration, and hopefully progress will not be derailed by primary care’s painful evolution. People want better access to care. PCPs want better care for their patients. As these needs surface, our care systems are struggling to accommodate them. Integration still faces many operational and financial hurdles, but our field should rank it high on its list of priorities.

Ed Jones, PhD, is currently with ERJ Consulting, LLC and previously served as President at ValueOptions and Chief Clinical Officer at PacifiCare Behavioral Health.

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.