CURRENT BOOKS: Marrying Medicine and Psychiatry

Comprehensive Care for Complex Patients: The Medical-Psychiatric Coordinating Physician Model, by Steven Frankel, MD, James Bourgeois, OD, MD, and Philip Erdberg, PhD, Cambridge University Press, 201 pages (2013).

Traditionally, when a patient was referred to a psychiatrist, he or she would disappear into a great void, where no one except the psychiatrist and the patient would know what was transpiring. Primary care physicians would typically rely on the patient to find out such things as the psychiatric diagnosis and the medications that were prescribed.

If the authors of Comprehensive Care for Complex Patients had their way, the psychiatrist would be forced out of this disappearing act and into a key role as the coordinator of care for “complex” patients with multiple comorbidities. The authors--two local psychiatrists and a psychologist--describe this new type of psychiatrist as an MPCP: a medical-psychiatric coordinating physician. They acknowledge that MPCPs would need additional training in medical areas, possibly through a post-residency fellowship. In their view, MPCPs would be instrumental in managing the care of those 10% of patients who demand up to 70% of a primary care physician’s time. They further posit that it makes sense for psychiatrists to assume the MPCP role because many of these complex patients have a mixture of medical and psychological issues, with one affecting the other.

Through exhaustive research (there are nine pages of references), the authors lay out a convincing argument for having a key person, the MPCP, coordinating care. They clearly demonstrate that many things are missed when one does not conduct a thorough initial evaluation, including interviewing the patient, family members, and past and present medical providers, as well as laboratory testing, scans, and psychometric testing.

At times, I found the book to be a bit heavy in introducing new terms, and it is also somewhat repetitive. Nonetheless, it is an easy read that can be finished in one sitting. The case studies are particularly helpful and entertaining. In these studies, physicians will readily recognize that we all have treated patients like this, usually ineffectively. Adopting the MPCP model would definitely serve these patients better.

Besides advocating collaboration with the primary care physician and other specialists, non-MD providers and family members, the MPCP model advocates “truing” as a method of improving care. I was not familiar with this term. When the authors described it in mathematical terms and likened it to approximating the asymptote, I began to understand it better--through gathering further history, interviewing family members, and performing psychological and lab testing, the clinician is always revising his assessment and treatment plan.

Of course, this is the way we all try to practice medicine, but often due to time constraints, we fall short. In fact, if I had one criticism of the MPCP model, it would be just that: Who has the time to treat these patients so exhaustively? If I served the MPCP role, I probably would have to cap myself at about 20 total patients.

The question of time brings up another issue regarding the MPCP model: Is it cost-effective? One could argue that by coordinating care with just one “point person,” we are cutting down on redundancy and freeing up the time of the collaborating physicians and possibly catching severe diseases in an earlier phase. However, at what expense? I could see the physician who signs up for the MPCP role spending several hours collaborating with other providers for every one hour he meets with the patient.

I started my private practice in psychiatry at the same time that managed care arrived. I was quickly shuttled into the role of medication management and more or less restricted from performing psychotherapy. Why pay a psychiatrist $100 an hour (back in 1990) to perform psychotherapy when an LCSW or MFCC would do it for $50?

Given these realities, I can only see the MPCP model working in two scenarios: (1) the MPCP doesn’t mind making much less money and not getting reimbursed for time spent outside of the therapy hour, and (2) charging patients and their family privately. The latter may prove difficult because complex patients often end up on disability and/or public assistance. Unfortunately, the authors dedicate only a few pages to the issues of cost.

On the other hand, the authors have completed a pilot study of 52 patients who have been in the MPCP system. As a next step, they are going to compare patients treated with MPCP to those treated with other modalities. I look forward to seeing the results of their research.

In summary, the authors make a convincing argument through extensive research and case studies that the MPCP model would greatly improve the care of the most difficult-to-treat patients. Where and how this model can fit into medicine in 2013 and going forward with Obamacare remains to be seen.

While I doubt that I will incorporate everything this book suggests into my own practice and become an MPCP provider, I will certainly use some of its main suggestions: conducting a thorough initial interview; coming up with a treatment plan; constantly revising that plan based on new information gathered; and seeking out collateral information from key players in the patient’s life. I will also make a more sincere attempt to keep the primary care physician in the loop.

Psychiatrists who see complex patients will probably find this book helpful. Primary care providers may also enjoy reading it and learning to incorporate some of these same techniques into their practice.

---

Dr. Barshack, a psychiatrist in private practice in Corte Madera and Petaluma, served as medical director of psychiatry at Marin General Hospital from 1995 to 2010.

Email: scottb246@mac.com