Resident’s Perspective on a Changing Health Care System

I think I can speak broadly for most of us traversing the sometimes turbulent waters of medical training when I say that there are intense periods that often radically shape the course of our careers and what we want out of a life in medicine.

I didn’t begin medical school with psychiatry on my radar, and it was a confluence of public-health arguments coupled with amazing clerkship experiences that hooked me. At some point near the end of my third year in medical school, it was clear that surgery and probably obstetrics had failed to capture my attention in the same way as behavioral health, and my focus narrowed. Such narrowing isn’t unusual in medicine. Gone are the days of the uber-generalist—even primary care has developed niche areas of practice. Increasing interest in sports medicine or hospitalist fellowships arising out of family medicine come to mind. It’s inevitable that we all narrow our scope over time and stake our claim within the ever-expanding global map of medical knowledge.

In this vein, I consider the great potential for practice reform within the field of psychiatry currently taking place. Dramatic shifts are occurring in the practice of medicine as health care needs evolve, and our profession must adapt. However, as we prune our medical knowledge, so too do we sometimes focus our notions of psychiatric practice in ways that limit our potential and threaten our profession.

Most young psychiatrists don’t begin postgraduate training with a developed sense of how the health system is structured or their place within it. A trainee’s role in psychiatric consultation is a blank slate. It’s the first three years of residency education that often define our scope and boundaries with seeing patients and our professional relationships with colleagues in mental health care and in the rest of medicine. It’s the first three years—our attendings and mentors during that time—that are responsible for dictating our comfort in consultation and breadth of medical management for the rest of our professional lives. Perhaps because our notions of the practice of psychiatry are more fluid, and linkages with colleagues from medical school more palpable, that less-experienced clinicians are more apt to embrace new models of mental health care delivery, such as the shift to integrated and collaborative care that is now under way.

To be sure, I’m speaking generally—there are significant exceptions everywhere—but if engaged early enough, before traditional notions of psychiatric practice solidify, and with the right incentives and mentorship in place, I’ve found that practicing in integrated care settings has wide appeal among trainees interested in working within teams and assigning their expertise across populations of patients.

While most residents don’t see working in collaborative care—meeting with a care manager and reviewing a caseload of patients to identify those most in need of attention and communicating management recommendations to primary care physicians—a full-time job, some do. Practice systems that have embraced reimbursement for collaborative care consultation and time, such as those in Washington state and Minnesota, and that offer education and mentorship experiences in integrated care, are filling positions and redefining what it means to practice as a psychiatrist.

APA, through the leadership of Lori Raney and others, has developed the capacity to disseminate the necessary skills for practicing in collaborative care settings and is working passionately to provide those opportunities to members, but there’s a feeling that the workforce is slow to embrace new models of care.

The challenge to building workforce capacity in integrated care isn’t garnering interest or necessarily overcoming payment reform—it’s reaching us early enough to alter our career trajectory so that it encompasses a broader vision for psychiatry in the 21st century. It’s providing a chance to work in a collaborative care setting early in residency, or even medical school clerkships, and supplying a model of innovative psychiatric practice that is as rewarding as our traditional models before preconceptions about professional identity take root.

It is not to say that the more experienced workforce is incapable of practice evolution, it’s just that we should focus more resources on training to the components of the health care system most likely to change and commit to integrating these evidence-based models into every postgraduate training experience. With the right incentives, experiences, and opportunities in place, we can radically reshape the course of our profession within the house of medicine, as well as what we’ve come to expect from a life of service to others. We can lead the pack among all medical specialists who share similar concerns with chronic disease management and primary care integration. We can navigate the turbulent period of health care reform by trusting in the models we’ve created to deliver effective care across the entire population and secure our practice and our specialty for future generations. As I embark on a career in mental health care, I couldn’t ask for anything more. ■