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Clinical Svcs Symposium

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  • 1. Child and adolescent psychiatry’s role in a professional dilemma Bela Sood, M.D. Virginia Commonwealth University Douglas Robbins, M.D. Maine Medical Center Co-Chairs, Clinical Practice Committee, SPCAP
  • 2. MCO’s/ Litigation & other Monsters: Setting Expectations for Professional & Ethical Clinical Practice
  • 3.
    • The practice of modern medicine…..disparities, dependence on market forces to transform health care systems, tempts physicians to forsake their traditional commitment to the primacy of patient interests
    • To maintain the fidelity of our contract with society : have to reaffirm our dedication to the principles of professionalism for not just our individual patient but to the health care system as a whole and thus improve health care for society overall..
  • 4.
    • Medicine’s contract with society:
    • pt interests above those of the physician: market forces must not impede this
    • Pts autonomy: empower to make the right decision with shared knowledge, honesty about medical errors
    • Principles of social justice: fair distribution of health care resources, (reducing discrimination)
    • Commitment to improving quality of care, improving access to care
  • 5.
    • Commitment to setting competence and integrity standards (life long learning), expert advice on maters of health
    • Commitment to the integrity of scientific knowledge that is based on evidence/experience
    • Commitment to honor the relationship by not exploiting the dependent vulnerable position for the patient for financial, sexual or other personal reasons
    • Commitment for managing conflict of interest in order to be trusted
    • Self regulation, remediation and discipline of members who do not meet professional standards.
  • 6.
    • The ethics and professional standards of practice as we define it as a profession
    • The external elements that impact our ability to deliver care ethically and professionally
  • 7. Clinical work….and Academia?
    • Financial viability?
    • Keeping up with the competition?
    • Outsourcing or developing niche
    • All things to everyone or “boutique” operation
    • * Central to mission of the operation
  • 8. Erosion of Life as we knew it
    • Time constraints
    • Man Power shortage
    • Reimbursement
    • Mismatch between expectations and “delivery of goods”
  • 9. Role of Technology
    • (New) Knowledge used as a “stick” by consumers and “gatekeepers”
    • Challenges:
    • How to…..stay ahead
    • avoid defensiveness
    • set standards for trainees
  • 10. Role of the child psychiatrist
    • “ Pill Pusher”
    • “ Holistic Treator”
    • “ Psychotherapist”
    • “ Diagnostician”
    • Or
    • All to some
    • Or some to all
  • 11. The brave new world….
    • The emergence of managed care organizations
    • The evolution of MCO’s
    • The role of physicians
    • The role of this middle man
    • “ To play or not to play” is the question
    • Anti trust and health care laws
  • 12. Managed Care Organizations
    • Challenges:
    • How and when enough is enough?
    • How to impact practices of MCO’s
    • How can our colleagues who serve as medical directors impact policy for MCO’s?
    • Role of The Insurance Commissioner and SEC
    • Role of antitrust and health care law
  • 13. Litigation
    • Not a high risk specialty
    • But
    • the specter of metabolic syndromes and “black box warnings”….”drug drug interactions
    • The potential for violence
    • The appearance of “inaction”
    • The “relationship” problems with families/ other disciplines
  • 14. Mitigation of Risk
    • A focus on understanding the risks and why they exist
    • Developing a rationale for why we do what we do
    • Helping trainees develop rational logical paradigms for clinical care, skills for clear articulation
    • Focus on relationships, listening with the “third ear”
  • 15.
    • Patient abandonment
    • Inappropriate behavior with pt/colleague…. example
    • Inappropriate management of patient
    • How does termination occur: “firing and hiring”
    • Do doctors “tell” on doctors or “guild” protection….. physician heal thyself
  • 16. When in doubt is there help?
    • Supervision with colleague
    • Professionalism committees set expectations at school level: rules/ behavior
    • Ethics in clinical practice: university risk management/legal team
    • Ethics committee of AACAP
  • 17. Standard for Trainee
    • Challenges:
    • Working in a multidisciplinary team
    • Espousing a “democratic” decision making process
    • Maintaining authentic and safe medical management
    • Fine line before “autocratic/respondent superior” role emerges
  • 18.
    • Standards of Professional Behavior
    • These standards describe behaviors expected from faculty, housestaff, and students in the School of Medicine:
    • Recognize their positions as role models for other members of the health care team.
    • Carry out academic, clinical and research responsibilities in a conscientious manner, make every effort to exceed expectations and make a commitment to life-long learning.
    • Treat patients, faculty, housestaff and students with humanism and sensitivity to diversity in characteristics such as culture, age, gender, disability, social and economic status, sexual orientation, etc. without discrimination, bias or harassment.
    • Maintain patient confidentiality.
    • Be respectful of the privacy of all members of the medical campus community and avoid promoting gossip and rumor.
    • Interact with all other members of the health care team in a helpful and supportive fashion without arrogance and with respect and recognition of the roles played by each individual.
    • Provide help or seek assistance for any member of the health care team who is recognized as impaired in his/her ability to perform his/her professional obligations.
    • Be mindful of the limits of one's knowledge and abilities and seek help from others whenever appropriate.
    • Abide by accepted ethical standards in the scholarship, research and standards of patient care.
    • Abide by the guidelines of the VCU Honor System .
    • These standards were proposed by the Professionalism Committee and adopted by the School of Medicine in September 2001. The standards are also available in print in the form of pocket cards and posters . Contact Debbie Stewart (804-828-6591, [email_address] ) for copies.
  • 19. Professionalism
    • Transparency
    • Honesty
    • Accountability
    • Unafraid to get the “job” done, yet not seen as “on a power trip”
    • Emotional intelligence to determine “timing”
    • The role of “mezzanine” people
  • 20. Ethics
    • When to say no to patient care?
    • Evidence based practice vs. Instinct
    • The ideal and the real
    • Clear rationale: 3.5 year old….
  • 21. Audience input….
  • 22. Challenges in implementing Evidence-Based Practices: Child and Adolescent Psychiatry’s role in this professional dilemma
  • 23. Dilemmas
    • Child and adolescent psychosocial treatment often has limited effect. (E.g. Weisz JR, 2004)
      • The public health impact of what we do is insufficient.
    • Child Psychiatry has a significant array of EBPs, but they are rarely really implemented.
    • We are often reinforced for continuing previous patterns of practice.
      • Reimbursement patterns, Medicaid and insurance rules continue the status quo
    • The Feinstein Challenge: We train residents in development and the art and science of treatment, and then their practices involve primarily medication management. Is this the role we intend for them?
      • SPCAP 2007
  • 24. Barriers to implementing EBPs
    • 1. Limited applicability of the evidence to clinic populations
    • 2. Costs of implementation
    • 3. Clinicians’ discomfort with EBTs
    • 4. Lack of outcome assessment in clinical work
    • 5. Organizational culture
  • 25. 1. Limited applicability of the evidence to clinical populations
    • Discrepancies between efficacy trials and effectiveness.
    • Heterogeneous clinical populations
      • Comorbid disorders
      • Social, economic, cultural diversity
    • (Hoagwood K, et.al., 2001)
  • 26. Potential Solutions to the limited applicability
    • Common Elements or Modular approach. Menu of components. Matched to individual patient characteristics
    • (Chorpita BF et.al., 2007)
    • Evidence-Informed Practice vs. Evidence Based Practice
    • (Hamilton J, 2005)
  • 27. 2. Costs of implementation
    • Direct costs of training and supervision
    • Training time is not reimbursed
    • Some EBPs not reimbursed
      • Parent Management Training – without patient present
      • In-home treatment
      • Collaboration with schools and primary care
    • Administrative time and costs
    • Costs of outcome assessment
  • 28. Potential solutions - Cost
    • Outcome-based reimbursement
      • Risk of discouraging treatment of more difficult patients
    • Differential reimbursement for clinicians or programs using EBPs
      • E.g. adult ACT teams in New York – treatment fidelity related to rate
    • Case rate reimbursement vs. fee-for-service
  • 29. 3. Psychiatrists’ and clincians’ discomfort with EBPs
    • Limitations of time for training and supervision
    • Limitations on clinical contact time – Managed care
    • Large number of EBPs – too many to learn
    • Perceptions of rigidity or poor fit with patients
      • Comorbid disorders
      • Cultural and economic diversity
  • 30.
    • Discomfort with EBPs - continued
    • Top-down decisions to use EBPs
    • Perceptions that EBPs are not needed
    • Factors associated with openness to innovation.
      • Temperament
      • Support vs. anxiety, insecurity.
      • (Aarons GA, 2005)
  • 31. 4. Lack of outcome assessment in clinical practice
    • “ The Bell Curve” – New Yorker , 12/6/2004
    • Feasibility – Costs, burden to family
    • Absence of feedback loops for performance improvement
    • Potential mis-use of outcome data
      • e.g. negative reinforcement for treating difficult patients
  • 32. 5. Organizational culture
    • Macro-level – Disincentives to innovation.
      • Medicaid and insurance rules and practices.
    • Behavioral expectations and reinforcers.
      • “ Productivity”
    • Organization’s sense of the public health mission, vs. survival
    • (Glisson C, 2007)
  • 33. There’s hope – Initiatives on implementation of EBPs
    • Federal - NIMH, CMHS, SAMHSA, Other.
    • State initiatives
      • Colorado, Hawaii, California, Michigan, New York, Ohio
    • (Bruns EJ and Hoagwood KE, JAACAP, April, 2008)
    • MacArthur Foundation
    • Annie E. Casey Foundation
    • Annenberg (Foundation
    • (Chambers DA et.al., 2005)
  • 34. Tilting at Windmills? Advocacy for Evidence-Informed Practices
    • Individual case reviews with payors
      • Refer to Practice Parameters and EBPs
    • Cost-effectiveness and benefits to clinical organizations
      • Evidence of effectiveness
    • Medical-Legal support
    • Role of the AACAP
    • The child & adolescent psychiatrist’s role as leader of the multidisciplinary team
  • 35. Training
    • Development of familiarity and comfort with outcome assessment as a routine clinical practice.
    • Role of the CAP as one who knows what really works – whether or not we can do it now.
    • Maintain a focus on our responsibility to the community. Spokespersons for best practices.
    • Role as leader of the multidisciplinary team, aware of what is evidence-informed.

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