Child and adolescent psychiatrys role in a professional dilemma

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Child and adolescent psychiatrys 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
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MCOs/ Litigation other Monsters Setting
Expectations for Professional Ethical Clinical
Practice
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• 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..

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• Medicines 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

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• 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.

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• 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

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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

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Erosion of Life as we knew it

• Time constraints
• Man Power shortage
• Reimbursement
• Mismatch between expectations and delivery of
  goods

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Role of Technology

• (New) Knowledge used as a stick by consumers
  and gatekeepers
• Challenges
• How to..stay ahead
• avoid defensiveness
• set standards for trainees

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Role of the child psychiatrist

• Pill Pusher
• Holistic Treator
• Psychotherapist
• Diagnostician
• Or
• All to some
• Or some to all

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The brave new world.

• The emergence of managed care organizations
• The evolution of MCOs
• 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

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Managed Care Organizations

• Challenges
• How and when enough is enough?
• How to impact practices of MCOs
• How can our colleagues who serve as medical
  directors impact policy for MCOs?
• Role of The Insurance Commissioner and SEC
• Role of antitrust and health care law

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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

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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

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• 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

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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

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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

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• 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, dstewart_at_vcu.edu) for
  copies.

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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

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Ethics

• When to say no to patient care?
• Evidence based practice vs. Instinct
• The ideal and the real
• Clear rationale 3.5 year old.

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Audience input.
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Challenges in implementing Evidence-Based
Practices

• Child and Adolescent Psychiatrys role in this
  professional dilemma

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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

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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

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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)

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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)

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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

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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

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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

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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)

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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

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5. Organizational culture

• Macro-level Disincentives to innovation.
• Medicaid and insurance rules and practices.
• Behavioral expectations and reinforcers.
• Productivity
• Organizations sense of the public health
  mission, vs. survival
• (Glisson C, 2007)

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Theres 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)

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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 psychiatrists role as
  leader of the multidisciplinary team

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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.