We spend so much more time talking about how to pay for health care in the United States than we do wondering if what we get is worth what we pay. My fields are family medicine and psychiatry, and to my
chagrin, rarely do these two specialties communicate. Here's an example of a situation resulting from the separation between these fields that is unfortunately common and very expensive.
Recently, a mother became concerned about her 10-year-old son's feeling sad. She talked to him enough to learn that he was being bullied at school and sometimes wondered if it wouldn't be better not to be here.
She took him to their family doctor who said he didn't do mental health, telling her she had to go to the emergency department at the hospital to access services quickly.
At first this sounds crazy, but in our health care system, the fastest way to get an appointment at the community mental health center is to go to the emergency department. Otherwise, one could wait months for an appointment (at least where I work). It's more questionable for the family doctor to say, "I don't do mental health." We have extensive training in handling mental health issues during our three year residency. In Canada, where residency training is only two years, family doctors are expected to manage all mental health issues with psychiatrists available only as consultants.
This mother promptly drove to the local emergency department of a hospital just outside New York City. Luckily, she had gone to the family doctor early in the morning because they waited five hours to see a physician. He asked the son a few questions. The coup de grace came when he asked the boy if he ever felt as if it would be better if he were not here. The boy agreed. Sometimes he thought that way. The physician left the room for an hour and returned to announce to the mother that he was transferring the boy to the psychiatric center by ambulance, because of his suicidal ideations. The mother objected. "I can take my son in our car to somewhere else to be evaluated, just like I brought him here." The physician left the room and returned with a social worker and two security guards. They told the mother that she would be arrested and detained if she interfered with the transfer of her son by ambulance, and that Child Protective Services would be involved because of her failure to recognize the gravity of the situation and that her son needed immediate treatment. After briefly arguing that it was she who initiated the request for services and receiving an even more threatening response, she acquiesced and followed the ambulance in her car. By now, her son was terrified. Protocol demanded that he be strapped to a stretcher for the trip.
At the psychiatric center, they waited another five hours before seeing a social worker who took the history. Then a resident came to talk to her and the boy. The mother dug in her heels, objecting to admission, and insisting that sometimes thinking it would be better not to exist was different from having a plan and a means to harm oneself. After three more hours -- a total of eight hours at this center -- an attending physician turned up who agreed with the mother and wrote a prescription for 5 mg of escitalopram, a selective serotonin reuptake inhibitor (brand name, Lexapro). He also gave her some names of some private therapists to call in their home community. Imagine the charges stacking up. The family doctor billed for an office visit. The emergency department charged almost $2,000 for their evaluation. The psychiatric center charged $2,500 for their evaluation. The ambulance transfer had cost $500. The prescription cost $80.
At the psychiatric center, a social worker and two physicians had finally agreed with the mother that her son had no plan to kill himself, but only sometimes wondered if it would be better not to exist. In fact, until his encounter with the psychiatric system, the mother told me that he had not actually considered that people really killed themselves. His concept had been more wistful and fanciful as he wondered about disappearing (a common response to being bullied at school). Presumably others have wondered the same thing. The mother's observation was that each time she and her son were transferred, her son was becoming more frightened.
In the end, after an extra $6,000 in billing and probably the worst day of this mother and son's lives, the result could have happened in the family doctor's office in a 15 minute visit. He could have listened to the mother and the child, and could have made a determination that these thoughts were not connected to a plan or to an intent to die, but rather an expression of how miserable the child felt. He could have written the same prescription since this drug is widely detailed to family doctors with instructions on its use. He could have given the mother names of psychotherapists in the community to call. In an enlightened office, he could have had a therapist on call for his office or visiting on a regular basis each week to handle these kinds of situations.
Why didn't he? One explanation is the silo model of American medicine. Each specialty keeps to its own domain somewhat exclusively. Family doctors don't talk to psychiatrists and don't treat psychiatric disorders. Similarly, psychiatrists don't talk to family doctors and don't treat medical disorders. Nobody listens to the whole story. However, the body and mind are one. The arbitrary separations we create do not actually exist in nature. Physical and mental suffering are linked. I believe that much of our distress
results from a disconnect between us and the community, the idea that medicine includes an understanding of ourselves as connected to each other, that the story is not of ourselves as isolated patients but of our collective social relationships. As an example of that, probably the most enlightened intervention for this child would have been to go to the school to address bullying, but medicine rarely does that. We treat the individual patient rather than the situation that's causing the patient distress.
Of course, the other big impetus is the risk of being sued for malpractice. This stops physicians of all kinds from taking the risk of making common sense decisions that reflect this humanist understanding.
If we are going to actually afford an accessible health care system, we will need to address these questions of how care is delivered. Failure to do this will bankrupt our health care budget.