The buzzwords now in Family Medicine. Integrated behavioral health in primary care. I am finding it a bit annoying.
Integrated does not mean race in this context. It just means the clinic should have a behavioral health person.
I suppose that is a good idea maybe, or might seem like one. But what do they think I have been doing for thirty years? Ignoring behavioral health?
Really, primary care is half or more behavioral health, if a primary care doctor gives people time and pays attention. People have an average of 8 colds a year. Why do they come in for cold number 4 if it is no worse than all the others? Because the cold in not really why they are coming in. The cold is the excuse. Notice that the person is there, that they are not that sick, that they do not care that you are not going to prescribe antibiotics.
I have my hand reaching for the door when an older patient says, “May I ask you something?” She came in for something that she didn’t seem to care about, so I am not surprised. I turn back. “Yes.”
“I have friends, in another state. They had a baby. The baby is very disabled.”
I sit down. This is more than 15 years ago, so I do not remember what the baby had. Hydrocephalus. Cerebral palsy. Something that requires multiple doctors and physical therapy and the parents are grieving.
“What bothers me most is that they have to struggle so much for services. There is very little support and very little money set aside. One of the parents has quit their job. It is a full time job taking care of this child and they are frightened about the future. Is this really what it’s like?”
And that is the real reason for the visit. “Yes,” I say. “It can be very difficult to access services, you have to track down the best people in your area, some physicians won’t pay much attention and others are wonderful. And the same with physical therapists and everyone else. Tell them to find some of the other parents of these children. Get them to recommend people. And the parents have to be sure to take care of themselves and each other.”
She frowns. “It’s a nightmare. Their life completely changed from what they thought. First baby. And it is overwhelming.”
“I am sorry. You are welcome to come back and ask me questions or just talk.”
“Thank you. I might.”
“Do you need a counselor?”
“No, I’m fine. I am just worried about them and feel helpless.”
“It sounds like staying in touch is the best thing you can do.”
The true reason for the visit is often something entirely different from what the schedule says. Sometimes people are there without even knowing why they came in. “Can I ask a question?” That is key. Saying to see people for one thing is criminal and terrible medicine and makes behavioral health worse. There is so much we can do in primary care just by listening for these questions and making time for them.
I have nothing against adding a behavioral health person to the clinic. They talked about “embedding” a behavioral health person in each group of soldiers back in 2010, when I worked at Madigan Army Hospital for three months. I always pictured digging a hole in my clinic floor, capturing a counselor, and then cementing them in the hole. I would have to feed them, though. I always thought that was sort of a barrier. One more mouth to feed. I found it more useful to contact counselors, ask what they wanted to work with, learn who knew addiction medicine, learn who was good with children or families or trauma. And ask patients to tell me who they liked and why. I integrated behavioral health in my community, not just in my clinic, because there is no one counselor who is right for everyone.
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