Pioneer in C-L Psychiatry Traces Path to Collaborative Care

“Don, why are you still banging your head against the wall?”

The question was asked by a physician colleague who had, in frustration, abandoned his own efforts to teach elements of clinical psychiatry to practicing nonpsychiatrist physicians. Rising to the challenge to explain to him and myself and how I got that way, I reviewed the evolution of my own interest in what seemed (at least to him) like a masochistic pursuit. Having won a medical school essay competition in 1955 on the doctor-patient relationship under the nom de plume Theophrastus Bombastus von Hohenheim (aka Paracelsus), a 16th-century physician said to have contributed to the growth of psychiatry by way of alchemy, it was not a large segue to mind-body issues, then on to psychosomatics and ultimately consultation-liaison (C-L) psychiatry. It was not easy, but it was challenging, to enter the “back door” of medicine to try to reassemble what medicine (and Descartes) had rent asunder—a big step for psychiatry, a small step for medicine.

C-L psychiatrists were few, with many laudable models casting their lot into the quest: George Engel, an internist drawn to psychiatry and psychoanalysis by Maurice Levine and John Romano in Cincinnati, struggled valiantly until his final years, frustrated that acceptance had changed so little, even with his advocacy for biopsychosocial medicine. Practically every president of the American Psychosomatic Society beginning with its founder, Helen Flanders Dunbar, had expressed similar frustration with the sluggishness of success. Michael Balint, the Hungarian psychoanalyst who met with groups (“Balint Groups”) of general physicians, had written that change would occur in 150 years, which will not arrive until 2100 (encouraging!). Others, less prominently, had been drawn to the challenge: Nick Stratas of South Carolina; Nick Kates of Canada, who took consultation to the community and family practice; and David Goldberg and Linda Gask of the United Kingdom, who constructed organized programs for training nonpsychiatrist physicians. A C-L colleague, John Reichard at Boston’s Faulkner Hospital, had obtained a grant from the National Institute of Mental Health in the 1970s to place psychiatrists in physicians’ offices to observe and then discuss problems and possible interventions. I knew we were in trouble when I suggested my tutee could easily maintain a middle-aged woman with chronic schizophrenia in brief monthly sessions and with a small dose of a psychotropic drug, but he preferred to “treat” a disturbed pretty adolescent girl with borderline features who clearly required the skill of an adolescent psychiatrist.

In the 1960s, psychologist Nicholas Cummings at Kaiser-Permanente found that brief integrated care result-ed in decreased overutilization of medical facilities. I had a go at integrated care myself with the establishment in 1962 of the Integration Clinic, which tried to reduce the fragmentation of 45 specialty clinics at Boston’s Beth Israel Hospital, where Grete Bibring and Ralph Kahana were strong mentors and advocates of training physi-cians to “manage” their hospitalized patients’ emotional problems; physicians had to “own” their patients since no psychiatric beds existed in the hospital to which they could be transferred.

The 1970s spate of books by psychiatrists for primary care physicians was probably left untouched on bookshelves. The federal government, urged by the Institute of Medicine, encouraged medical schools to use 15 percent of their curricula in behavioral science if they expected to retain federal funding. Few psychiatrists became part of these programs.

And then there was Wayne Katon, a superior researcher and C-L psychiatrist, a quick, innovative learner who recognized soon that the old ways of instructing physicians simply were not working. With a dedicated group of associates using nurses and care managers, they essentially revolutionized the approach to assisting physicians with their “overutilizing” patients who had significant emotional aspects to their illness. Collaborative and integrated care became the preferred approach to helping nonpsychiatrists with their “difficult” patients. Instead of the fragmented clinics of the 1950s and 1960s, medical homes emerged to bring teams together that could offer collaborative care to growing numbers of patients.

The challenge of persuading others of the effectiveness of integrated collaborative care was often frustrating but mostly gratifying. We have a way to go, but we are moving in the right direction, and I would still urge young entrants to our profession to continue on that stimulating path. 2100 is not so far off! ■