Collaborative Care as a Way to Stave Off Burnout

I worked in a CMHC for 27 years. My residency training didn’t prepare me to consider that work with the most seriously ill people could be a skill worth recognizing. This took time for me to understand.

First, I found myself impressed and humbled by staff, usually case managers, who dedicated themselves at little recompense to the care of patients with severe illness. Then, over the years, there was the growth of relationships with my most difficult patients, born of long and difficult work together. Finally, I began to read the literature on poor health outcomes among people with severe and persistent mental illness. I began to feel that the primary duty of our agency was to treat the most severely affected.

I began to try to reorganize psychiatric services at my center to do a better job of making care accessible and effective for our most seriously affected patients.

When we started to make it our business to improve the accessibility of our services and the actual measured clinical outcomes of our patients and to demonstrate our value to them, the job of working as a psychiatrist got a lot harder. I wanted my docs to work with me to figure out how to see more patients and keep track of more factors, like physical health status. This is good work, but at the end of the day, it is still more work.

It was about this same time that the electronic medical record (EMR) appeared. I thought that this would be a good thing—it would feed us information about our patients to help us make diagnostic and treatment decisions. It would be possible to actually read my colleagues’ (previously illegible) notes—what a novelty!

It did not occur to me that these innovations and attitudinal changes, pretty much all of which I was completely on board for and which I tried to hasten into practice, would help transform psychiatric practice into something that many find exhausting and unrewarding!

As Anita Everett, M.D., then president of APA, wrote in a column in the July 13, 2017, Psychiatric News: “We know that things like excessive productivity quotas, limits on the time that we can spend with each patient, and documentation requirements are major sources of dissatisfaction for physicians. Some stressors that adversely affect psychiatrists specifically include limited resources, high work demands, and patient violence.”

So I find myself torn. On the one hand, I have an exciting sense of mission: to improve the care of those who need care the most; on the other hand, I recognize the toll that changing practice takes on me and my psychiatric staff.

What can help make this better? As Anita wrote later in her column, “…experiencing collegiality, fairness, and respect leaves us feeling more satisfied with our work.”

In my personal work life, I started to spend a half day to a full day’s worth of time directing and working as the consultant psychiatrist for a collaborative care program in a nearby Federally Qualified Health Center. I found that this offered opportunities for some of the practice features that have been shown to reduce burnout:

There is no going back to the “good old days” of psychiatric practice—this model left out too many people who need our care. Nonetheless, the most important aspect of traditional psychiatric care that is sustaining and affirming is, of course, the face-to-face encounter with the patient and family. By no means do I suggest that this be abandoned; there is no substitute for expert specialty psychiatry.

I do suggest that work in a team-based model, of which the collaborative care model is one, may serve as a mitigating practice against burnout as psychiatrists find a way to meet their clinical and personal goals in a challenging and fluid practice environment. ■