INT'L. J. PSYCHIATRY I N MEDICINE, Vol. 7(3), 1976-77
A PSYCHIATRIST'S EXPERIENCE IN A PRIMARY HEALTH CARE SETTING* HENRY E. SCHNIEWIND, JR., M.D. Instructor in Psychiatry Harvard Medical School Staff Psychiatrist Beth Israel Ambulatory Care Center
ABSTRACT
Psychiatrists have, for years, offered consultation to their nonpsychiatrist colleagues in many settings and have worked with them in a variety of ways. The development of new programs in primary medical care offers new challenges and opportunities to the liaison psychiatrist. This paper describes the experience of a full-time psychiatrist in a hospital-based primary health care setting. Special problems are encountered in developing working relationships with patients, physicians, nurses, social workers, administrators, and other members of the health care team. Effective resolution of these problems makes it possible t o offer comprehensive mental health services as an integral part of primary health care. This psychiatrist's role differs from other consultation-liaison functions by virtue of full-time economic, patient care, academic, geographic and administrative assimilation into the primary health care setting itself. It is suggested that this role is an effective way to bring supportive and educational psychiatric services to patients and providers of all levels of sophistication and need.
Introduction It is well known that psychiatric illness, particularly depression, is common among the physically ill [ l ] . Recent publications document the relationship between physical and mental illness [2, 31 and provide evidence that proper psychiatric intervention reduces the unnecessary utilization of medical services [4] . Medical patients tend to accept psychiatric diagnosis and treatment more readily when it is offered in a medical setting [5]. When they are referred *This work was supported by grants from the Carnegie Corporation of New York, the Committee of the Permanent Charity Fund, the Commonwealth Fund, the Robert Wood Johnson Foundation, and the Charles E. Merrill Trust.
229 @
1977, Baywood Publishing Co., Inc.
doi: 10.2190/XG92-5PUN-9Y1V-03AJ http://baywood.com
230 I HENRY E. SCHNIEWIND
elsewhere for treatment by psychiatrists unfamiliar with medical practice, the result is usually fragmentation of care. Psychiatrists have developed a variety of ways to integrate mental health services with medical practice. For many years the Integration Clinic at Beth Israel Hospital [5], staffed by psychiatric residents three half days a week, provided support for the medical staff, specialized treatment, evaluation and screening of reluctant or apprehensive medical patients. In the Tumor Clinic and the Home Care Service of the same hospital, a part-time psychiatrist worked closely with physicians, and was able to teach the principles of medical psychology in the care of severely ill and dying patients [ 6 ] . Fox [7] describes his experience in the general medical clinics at the Peter Bent Brigham Hospital where a psychiatrist is included on each part-time physician team. In their review of forty-four OEO-funded health centers, Scherl and English [8] describe health care teams with social workers to which psychiatrists are available for consultation and direct service. At the Martin Luther King Center [9] a psychiatrist or a psychologist attends team meetings and participates in clinic sessions in which patients are interviewed in the presence of the team. Fink et al. [lo] report that requests for consultation increased when psychiatric treatment was offered as a service in addition to consultation and diagnostic services alone at the Health Insurance Plan of Greater New York. Physicians gained a more realistic idea of what can and cannot be accomplished by psychiatric care and became more willing to carry patients themselves. Stratas and Cathell [ll] stress the importance of working in the physicians’ own setting and describe the experience of a psychiatrist who made regular trips to physicians’ offices in rural North Carolina. Fifty-eight out of sixty-four physicians effectively managed the aftercare of formerly psychiatrically hospitalized patients. Consultation alone, however, provides insufficient concrete evidence about the potential contribution of psychiatry to busy medical practitioners, nor does the consultant grow to appreciate fully the extent of the problems with which the medical staff struggle. Psychiatrists can take another approach by offering seminars in medical psychology, with either a short-term didactic or a long-term supervisory orientation [12-141. These seminars have been found to be quite successful in changing doctors’ attitudes and practices. But few physicians leave their own practices to attend. In their description of their own experience with these seminars, Zabarenko, Pittenger and Zabarenko [15] outline the characteristics of the participating and “control” physicians and their practices, and report a favorable effect of the seminars on physicians’ behavior. Prepaid group practices, such as the Harvard Community Health Plan, offer the opportunity for psychiatrists to work with and teach medical staff. Although the existence of separate departments presents some barriers to effective interaction, mutual work, teaching, consultation and therapy, all form
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an integral part of general health care in their setting [ 161 . Coleman and Patrick [ 171 describe the direct integration of social workers, clinical psychologist, and psychiatric nurse as members of health care teams in the Community Health Center Plan of New Haven, a prepaid plan with 17,000 enrollees. At a cost of $0.55 per enrollee per month, the enrollees can receive brief psychotherapy from these mental health workers, with the psychiatrist serving as director and consultant. The psychiatrist’s role is not defined further. Borus et al. [18, 191 describe four interactional models between Community Mental Health Centers, Neighborhood Mental Health Systems and nineteen Boston Neighborhood Health Centers: 1. a “joint endeavor” model in which mental health staff are located at least part-time in the neighborhood health center and are paid from several sources, 2. an “Autonomous Neighborhood Health Center Model” in which the mental health program is totally funded and run by the health center, 3. a “Community Mental Health Center Outpost Model” in which mental health staff are paid by the Community Mental Health Center and assigned to work in the neighborhood health center, and 4. a “consultative model.” Morrill [20] suggests that a large part of mental health services should be integrated clinically, administratively, and financially into comprehensive health care. He also concludes that medical care providers cannot readily use part-time consultation or full-time but separate services. Lipowski [21, 221 advocates that “the primary basis of operation for psychiatric, or mental health, consultants should be the health care system alongside other health professionals.” Although such consultation-liaison psychiatrists provide valuable links between psychiatry and medicine and many are actively involved in research and teaching in the psychosocial aspects of primary health care, they are not usually an integral and functional part of the comprehensive health care system itself. Fink and Oken [23] present evidence that psychiatry is a primary care specialty providing first contact medicine, longitudinal responsibility, and an integrationist function for the patient. Lazerson [24,25] describes an exclusively teaching role for a consultation-liaison psychiatrist in a Primary health care setting. This paper describes one psychiatrist’s experience in providing psychiatric services as an integral part of a primary health care system in a hospital setting.
The Setting The Beth Israel Ambulatory Care Center [26] consists of five service delivery units: internal medicine, pediatrics, obstetrics-gynecology , medical
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walk-in and home care. Its establishment on October 1, 1972, with its own cost-revenue center and a full-time staff of about fifty represented a complete reorganization of the existing general out-patient services. Patients seeking medical care are now served by small teams consisting of a physician, nursepractitioner, social worker, receptionist, nutritionist and health assistant. House staff and medical students are regularly assigned to work with them. These eight teams receive clinical and administrative support from a seven member “core team” made up of the Medical Director, Administrator, Assistant Administrator, Psychiatrist, Research Adviser, Social Service Coordinator for Ambulatory Care, and the Assistant Director of Nursing for Ambulatory Care. The Center’s volume is about 50,000 visits per year. The psychiatrist is paid by the Ambulatory Care Center, where his office is located. He shares corridors, waiting room, and coffee pot with the medical staff and works with them in a wide variety of clinical, teaching and administrative ways. He spends half-time in direct, reimbursable patient encounters, and half-time in providing indirect services: consultation, staff education, clinical conferences, joint interviews, home visits, emergencies, administration, planning and research. By virtue of the economic, geographic, academic, administrative and patient care involvement in the Ambulatory Care Center, this psychiatrist’s role is different from that of the traditional consultationliaison psychiatrist. Since his patients already have a physician or nurse as their primary health care provider, he is not a primary care specialist as described by Fink and Oken [23].
The Building of Relationships Starting with the basic premise of full-time economic and geographic integration in the primary health care setting, the psychiatrist’s role has evolved through stages resembling several of the models described above. This evolution was brought about by relationship building and role negotiations with other members of the center’s staff, and by an ongoing process of mutual education. In the beginning, the Center’s staff members and administrators were preoccupied with the tensions produced by the reorganization of services and the formation of interdisciplinary health-care teams. Furthermore, they were unfamiliar with psychiatric practice and uneasy about the presence of a fulltime psychiatrist in their midst. At first, both the medical director and the psychiatrist thought the most desirable role would be that of consultant t o the staff. The psychiatrist would serve the patients mainly by supporting and improving the staffs mental health skills. This proved unacceptable to the physicians, who wanted the psychiatrist to take their difficult and “crazy” patients off their hands. The medical director served as an important mediator in clarifying the psychiatrist’s role with the physicians. The director reviewed
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with the psychiatrist the needs and pressures of primary medical practice. He encouraged the physicians to work with the psychiatrist on specific cases and to modify their expectations of instant, magical solutions for psychiatric problems. Discussion of the use of psychoactive drugs provided a good springboard for initiating communication and mutual respect. Specific plans were laid down for the psychiatrist to see some of the Center’s patients directly, and a mechanism for the scheduling and billing of psychiatric service was established. The psychiatrist asked to participate with the Center’s other physicians in a biweekly peer review conference. In this way, routine psychiatric practice was made more visible and familiar to the Center’s nonpsychiatrist physician staff. The mutual education of administrator and psychiatrist began at the time of the first major budget and staffing review. A delay of six to seven months between billing and collection had produced a falsely low income figure for psychiatric services. This reinforced the common impression among hospital administrators that mental health services are poor income producers and are, therefore, impractical. Fortunately, the psychiatrist had kept his own weekly list of patients seen, charges rendered and income expected. Thus, within a day, he was able to place a graphic summary of accounts on the administrator’s desk. The ensuing discussion served to solidify the administration’s commitment to the psychiatrist, and to expand the psychiatrist’s understanding of administrative pressures. The building of good relationships with the Center’s ten social workers was complicated on both sides by the competitiveness that comes from having similar professional backgrounds, and from uncertainty in the perceptions of other staff members. Concrete services such as helping patients with welfare, public assistance, housing and the like were clearly accepted as social services. When psychosis, severe suicide risk, psychoactive medication, hospitalization and complicated diagnostic issues were at question, the staff turned to the psychiatrist. However, in the broad area of psychiatric diagnosis, patient management, counseling and psychotherapy, many of the social workers had training quite similar to that of the psychiatrist, and the non-mental health staff was initially confused about when to call on whom for what. The relationship between psychiatrist and social worker was further complicated by an administrative difference between this medical setting and the usual mental health setting in which social workers come under the administrative and supervisory responsibilities of the psychiatrist. In the Ambulatory Care Center the social workers are responsible to the social service coordinator, who in turn reports to the medical director and the administrator. The psychiatrist had to establish co-worker relationships with each social worker by meshing his areas of clinical expertise with their particular interests and skills. A relationship was worked out with the coordinator of social services in which she bears the administrative and supervisory responsibility for the social
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workers, and the psychiatrist takes responsibility for consultation and back-up services to them. This arrangement has enabled social workers and their medical teams to treat very difficult patients, has resulted in a rewarding variety of available psychotherapeutic skills, and has given the psychiatrist time and freedom to relate uniformly and effectively with everyone on the Center’s staff. In this primary care setting, the psychiatrist has learned to appreciate the advantages of freedom from administrative responsibility for large numbers of mental health professionals. A role with the nurses also evolved from shared work with patients. Since the Center has no psychiatric nurses, the nursing staff at first turned to social workers for assistance with their patients’ emotional problems. Gradually, they began t o ask the psychiatrist as well for evaluations, treatment suggestions, and help in understanding their own feelings about patients. A paper written by one of the nurse-practitioners and the psychiatrist about the management of a patient was a most effective way to establish mutual respect [27]. Through their contacts with the psychiatrist and the social workers, nurses have learned enough about psychiatric management to function effectively with severely disturbed patients. Often the nurse is the provider to whom a mentally ill person relates the best. Because of their rapport with patients, nurses have been effective in preparing them for psychiatric consultation. Patients coming to the Ambulatory Care Center identify their main problems as physical. A large percentage of the patients are over sixty-five and tend to reject the idea that some of what they feel may be related to psychological conflicts. Many psychotic and borderline patients flatly refuse involvement with the mental health staff and can completely disrupt the medical system. Coping with these patients depends upon teaching staff how to recognize and contain their own feelings, to communicate quickly with each other and to set consistent limits. The psychiatrist was more readily accepted by patients as a working member of the medical team when introduced by their primary health care provider in the context of this kind of collaborative effort. Because of his involvement in a special kind of practice, the psychiatrist in primary health care can easily become isolated from his psychiatric colleagues. Even though the psychiatrist in the Beth Israel Ambulatory Care Center is a member of the hospital’s academic Department of Psychiatry, special efforts had to be made to build relationships in the department. Guidelines had to be established for help with emergencies and with hospitalizations. It was particularly important to arrange for regular consultation with the department’s Director of Adult Services. Understanding and communication improved even further when the psychiatrist worked with various members of the Department and the primary care center to secure federal funding for the training of a psychiatric fellow for future work in primary health care.
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Present Activities The psychiatrist’s present role is the result of the relationships he developed with staff and patients. The way in which the primary health care staff is organized for patient care and teaching provides the structure in which he works. Direct patient care, the traditional work of the psychiatrist, continues to lend validity to and earn respect for the psychiatrist. Since the medical and social work staff know all of his patients, his psychiatric work becomes highly visible and interesting to them. During the year May 1, 1974 to May 1, 1975, the psychiatrist completed 900 patient encounters. Three hundred were for group therapy. Of the 600 individual encounters 270 were for long-term treatment, 120 for short-term interventions, 130 for medication and support, and eighty for evaluation. Of the 220 patients represented by this sample, seventy-five were considered neurotic, fifty-five psychotic, eighty character disorders and ten borderline. More than half of these patients had some form of third-party insurance coverage although many were self-paying. The money generated by these encounters adequately paid for the psychiatrist’s direct service time. The revenue and grants for teaching and research covered his full-time salary. A group therapy program, developed with one of the social workers, is one of the primary ways in which direct psychiatric service is made available t o the Center’s patients. There are groups for patients with similar medical problems such as chronic lung disease, heart disease, obesity, and severe physical handicaps. Other groups are organized around life-stage problems : depression in young adults; coping with middle age; support for the elderly; single motherhood; and becoming a father for the first time. A brief seminar on the elements of group process is given monthly by the psychiatrist to medical students and staff, and supervision is offered to staff members wishing to develop their skills in work with groups. Psychiatric evaluations are often requested by physicians, nurses, and social workers. Because of their exposure to psychiatric teaching, they usually form their own impression before asking for special help. In emergencies, the psychiatrist is asked to evaluate further the degree of psychosis, suicide Potential, danger to others, need for psychoactive medication, or hospitalization. Whenever possible, patients in need of hospitalization are admitted to the fourteen-bed psychiatric inpatient service so that the primary health care staff can more easily follow their progress. Psychiatric hospitalization has had to be arranged for one to five patients per month. In addition to evaluating the patients in a medical examining room or on one of the medical inpatient services, the psychiatrist goes to the patients’ homes when necessary. Using the problem-oriented format familiar to other providers, the psychiatrist writes directly in the patient’s medical record. In these brief, accessible
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notes, he conveys the essence of the problem in simple nonPsYchiatric language, and lists concrete suggestions for management. He has also altered his clinical practice to allow for brief interruptions when important. He carries a ‘‘beeper’’ with him at all times. Knowing this enables staff members to contain their anxiety and to manage well until the psychiatrist is free to consult with them directly. Once a week each health care team meets to review interesting and difficult cases. The psychiatrist goes to as many of these meetings as possible and is often specifically requested by a team to attend. This enables him to hear about a large number of patients and to keep in touch with the details of medical practice on each team. He is asked to comment on the psychiatric aspects of patient care, to offer management suggestions, t o speak briefly about a clinical syndrome or a particular psychoactive drug, or to help the staff understand, contain and use their own feelings for a patient’s benefit. For example, the staff has learned that anger directed toward a patient may be a clue to significant psychopathology in the patient rather than simply indicating willful unpleasantness [27]. One team became furious at a chronically psychotic woman with diabetes and liver disease who was alternately seductive, psychotic, in pain, or overdosed when she came in to see the physician and nurse. After her admission to the psychiatric ward, the team worked out a plan: the social worker would see her weekly for an hour; the psychiatrist made himself available for crises and counseling with family members; the nurse was to dispense medication weekly; and the physician arranged regular visits for medical follow-up. This division of labor among clearly identified team members has facilitated the management of many difficult patients who would otherwise have worn out a single provider. Providers have also learned who may and who may not improve with psychiatric treatment. In the situation just described, they no longer expect a complete cure of the patient’s psychopathology and are able to give their energy to a management plan that contains the situation well through years of ups and downs. Social service rounds are held weekly in both the medical and the obstetricsgynecology units. In this major staff educational effort, the psychiatrist assists in the presentation of cases and in the review of topics of social and psychological interest. These sessions present an opportunity to demonstrate and share knowledge, and to demythologize the process of psychotherapy. For example, when the psychiatrist discussed the young adults group after a year of treatment, the medical and nursing staff heard concretely how their patients had benefitted from this form of psychotherapy. Videotaped interviews are shown and discussed. In this way, the staff learns the specific differences between and the indications for the various types of psychotherapy. Teaching is an important part of the Ambulatory Care Center’s activities. After medical interns, residents and the supervising health care team see
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I 237
patients in the afternoon, they meet to review their work. At these meetings a social worker or the psychiatrist discusses the psychiatric aspects of particular cases. Two medical students a month work full-time as clinical clerks in the Center and participate in all teaching activities. The Center now has four primary care residents in training. The psychiatrist meets with them weekly for an hour to review clinical situations, to interview patients and to present didactic material. Each primary-care resident is expected to treat at least one patient in short-term psychotherapy in order to experience one form of psychotherapy first hand with hour by hour supervision by the mental health staff. As a member of the administrative “core” staff, the psychiatrist participates in long range planning, funding, research activities and priority setting for the Ambulatory Care Center. What has been described is a comprehensive role for a staff psychiatrist in a primary health care setting. He provides direct care as an on-line co-worker and shares the work of operating an integrated comprehensive mental health center. He enhances and supports the development of psychiatric skills through teaching, consultation, and general availability on a full-time, long-term basis. The following case illustrates some of the ways in which the psychiatrist works with patients and staff. A young couple, both chronically psychotic and refusing psychoactive medication, were referred to the Center by their private psychiatrist for prenatal care. After their first visit, the social worker on their obstetrical health-care team asked the Center’s psychiatrist to see them with her. He worked with the team to develop a management plan and the medical and nursing staff admirably contained the couple’s irrational fears and paranoia. Although delivery was hardly uneventful, the situation remained under control until the day the couple took the baby home. Then the father became disorganized and delusional, refused to accompany the wife and child home and said that he would not let them into their apartment in a town at some distance from the hospital. They all left in a flurry of confusion, only to reappear hours later in the emergency room. The social worker made arrangements for the mother and child to spend the night elsewhere, and the psychiatrist was able to persuade the father to take antipsychotic medication for the first time. The father came in the next day considerably more organized, and the team judged that the family could go home. The Visiting Nurse Association was to make daily visits, and the crisis team in their mental health catchment area was notified. A few days later all of the professionals involved were convened. The conference allowed them to share their anxieties and concern about the welfare of the child. The psychiatrist, acting as an administrator, said that he would take the responsibility for initiating a Care and Protection Order, if necessary, and went the next morning with the visiting nurse to investigate the home situation.
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Surprisingly, the baby was found to be well cared for in a fairly wellorganized apartment. The professionals, however, were predictably still at loose ends. The psychiatrist spent the rest of the morning at the local Mental Health Clinic and at the Visiting Nurse Association’s office. Misunderstanding: were cleared up and the way was paved for their private psychiatrist to resum treatment and to work with local professionals for continuing care of the family. This case illustrates the multiplicity of tasks and roles required of the psychiatrist in primary health care. He must follow through in a number of different clinical and community settings. This represented another important step toward his acceptance as a useful member of the Ambulatory Care CenteI staff. Summary For the psychiatrist to work successfully in a primary health-care setting, he has to develop a style of relating to other professionals that is neither rigid nor overly compliant, but one flexible and firm in illustrating the uses of interactional therapy and psychological concepts in the diagnosis and treatment of medical illness [28, 291. A stable, well-organized health-care setting with a medical director willing to support the role of the psychiatrist is essential. The psychiatrist needs to take pains t o familiarize himself with the pressures and demands of medical practice and to demonstrate his usefulness by working with patients. Familiarity with the broad range of psychoactive medication use is an excellent entree. Conditions for clinical practice should include physical location in the health care setting and arrangements for occasional interruption. The psychiatrist must know the pressures placed on his administrators and keep accurate records of his activities. He should participate in administrative planning and research. The psychiatrist who works in nonpsychiatric systems has to keep his lines of communication open to psychiatric colleagues as well. A working affiliation with a department of psychiatry in the same institution or nearby is essential. By working in a health-care setting the psychiatrist brings his skills to patients who often resist mental health care even when it is badly needed. Having established his usefulness by visibility and example, he is in a unique position to teach the principles of medical psychology to other providers. It is recommended that positions similar to his become an integral component of medical settings and future systems for the delivery of mental health services. REFERENCES 1. M. A. Stewart, F. Drake, G. Winokur, et al., Depression Among Medically I11 Patients, Dis. Nerv. Syst., 26, pp. 479-484, 1965.
A PSYCHIATRIST'S EXPERIENCE IN PRIMARY H E A L T H C A R E I 239
2. N. A. Cummings and W. Follette, Psychiatric Services and Medical Utilization in a Prepaid Health Plan Setting, 11, Med. Care, 6, pp. 31-41, 1968. 3. M. R. Eastwood, The Relation Between Physical and Mental Illness, University of Toronto, Buffalo, N.Y., 1975. 4. W. Follette and N. A. Cummings, Psychiatric Services and Medical Utilization in a Prepaid Health Plan Setting, I, Med. Care, 5 , pp. 25-35, 1967. 5 . D. R. Lipsitt, Integration Clinic: An Approach t o the Teaching and Practice of Medical Psychology in an Outpatient Setting, in Psychiatry and Medical Practice in a General Hospital, N. E. Zinberg, (ed.), International Universities Press, New York, pp. 231-249, 1964. 6. E. C. Payne, Teaching Medical Psychotherapy in Special Clinical Settings, in Psychiatry and Medical Practice in a General Hospital, N. E. Zinberg, (ed.), International Universities Press, New York, pp. 135-1 68, 1964. 7. H. M. Fox, Psychiatric Consultation in General Medical Clinics, a n Experiment in Postgraduate Education, J. Amer. Med. Assoc., 185, pp. 999-1003, 1963. 8. D. J. Scherl and J. T. English, Community Mental Health and Comprehensive Health Service Programs for the Poor, Amer. J. Psychiat., 125, pp. 16661674, 1969. 9. E. L. Lowenkopf and I. Zwerling, Psychiatric Services in a Neighborhood Health Center,Amer. J. Psychiat., 127, pp. 916-920, 1971. 10. R. Fink, S. S. Goldensohn, S. Shapiro, et al., Changes in Family Doctors' Services for Emotional Disorders After Addition of Psychiatric Treatment t o a Prepaid Group Practice Program, Med. Care, 7, pp. 209-224, 1966. 11. N. E. Stratas and J . L. Cathell, Psychiatric Consultation with Community Physicians, Hosp. Community Psychiat., 17, pp. 202-204, 1966. 12. A. J. Barthold, The Physician Education Project'of the American Psychiatric Association, Medical Meetings Magazine, United Business Publications, 1974. 13. M. Balint, The Doctor, His Patient and The Illness, International Universities Press, New York, 1964. 14. M. Balint and E. Balint, Psychotherapeutic Techniques in Medicine, Tavistock Publications, London, 1961. 15. L. Zabarenko, R. A. Pittenger and R. N. Zabarenko, Primary Medical Practice, a Psychiatric Evaluation, Warren H. Green, St. Louis, 1969. 16. M. J. Bennett, Personal Communication. 17. J . V. Coleman and D. L. Patrick, Integrating Mental Health Services into Primary Medical Care, Med. Care, 14, pp. 654-661, 1976. 18. J. F. Borus, L. A. Janowitch, F. Kieffer, et al., The Coordination of Mental Health Services at the Neighborhood Level, Amer. J. Psychiat., 132, pp. 1177-1181, 1975. 19. J. F. Borus, L. A. Janowitch, F. Kieffer, et al., Neighborhood Health Centers: The Mental Health Delivery System of the Future?, unpublished manuscript, presented at the American Public Health Association meeting, New Orleans, La., October 1974. 20. R. G. Morrill, A New Mental Health Service Model for the Comprehensive Neighborhood Health Center, Amer. J. Pub. Hlth., 62, pp. 1108-1 11 1, 1972. 21. 2. J . Lipowski, Consultation-Liaison Psychiatry: An Overview, Amer. J. Psychiat., 131, pp. 623-630, 1974.
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22. Z. J. Lipowski, Consultation-Liaison Psychiatry: Past, Present, and Future, in Consultation-Liaison Psychiatry, R. 0 . Pasnau, (ed.), Grune and Stratton, New York, pp. 1-28, 1975. 23. P. J. Fink and D. Oken, The Role of Psychiatry as a Primary Care Specialty, Arch. Gen. Psychiat., 33, pp. 998-1003, 1976. 24. A. M. Lazerson, The Psychiatrist in Primary Medical Care Training: A Solution to the Mind-Body Dichotomy?, Amer. J. Psychiat., 133, pp. 964966,1976. 25. A. M. Lazerson, The Psychiatrist as Teacher in Primary Care Residency Training: The First Year, Int. J. Psychiat. in Med., 7, pp. 165-178, 1976-77. 26. A. A. Berarducci, T. L. Delbanco and M. T. Rabkin, The Teaching Hospital and Primary Care: Closing Down the Clinics, N e w Engl. J . Med., 292, pp. 615-620, 1975. 27. K . A. Gruber and H. E. Schniewind, Letting Anger Work for You, Amer. J. Nurs., 76, pp. 1450-1452, 1976. 28. H. S. Abram, Interpersonal Aspects of Psychiatric Consultants in a General Hospital, Int. J. Psychiat. in Med., 2, pp. 321-326, 1971. 29. R. J . Kahana and G. L. Bibring, Personality Types in Medical Management, in Psychiatry and Medical Practice in a General Hospital, N. E. Zinberg, (ed.), International Universities Press, New York, pp. 108-1 23, 1964.
Direct reprint requests to: Henry E. Schniewind, Jr., M.D. Beth Israel Ambulatory Care Center Beth Israel Hospital 330 Brookline Avenue Boston, Massachusetts 022 15
A PSYCHIATRIST'S EXPERIENCE IN A PRIMARY HEALTH CARE SETTING* HENRY E. SCHNIEWIND, JR., M.D. Instructor in Psychiatry Harvard Medical School Staff Psychiatrist Beth Israel Ambulatory Care Center
ABSTRACT
Psychiatrists have, for years, offered consultation to their nonpsychiatrist colleagues in many settings and have worked with them in a variety of ways. The development of new programs in primary medical care offers new challenges and opportunities to the liaison psychiatrist. This paper describes the experience of a full-time psychiatrist in a hospital-based primary health care setting. Special problems are encountered in developing working relationships with patients, physicians, nurses, social workers, administrators, and other members of the health care team. Effective resolution of these problems makes it possible t o offer comprehensive mental health services as an integral part of primary health care. This psychiatrist's role differs from other consultation-liaison functions by virtue of full-time economic, patient care, academic, geographic and administrative assimilation into the primary health care setting itself. It is suggested that this role is an effective way to bring supportive and educational psychiatric services to patients and providers of all levels of sophistication and need.
Introduction It is well known that psychiatric illness, particularly depression, is common among the physically ill [ l ] . Recent publications document the relationship between physical and mental illness [2, 31 and provide evidence that proper psychiatric intervention reduces the unnecessary utilization of medical services [4] . Medical patients tend to accept psychiatric diagnosis and treatment more readily when it is offered in a medical setting [5]. When they are referred *This work was supported by grants from the Carnegie Corporation of New York, the Committee of the Permanent Charity Fund, the Commonwealth Fund, the Robert Wood Johnson Foundation, and the Charles E. Merrill Trust.
229 @
1977, Baywood Publishing Co., Inc.
doi: 10.2190/XG92-5PUN-9Y1V-03AJ http://baywood.com
230 I HENRY E. SCHNIEWIND
elsewhere for treatment by psychiatrists unfamiliar with medical practice, the result is usually fragmentation of care. Psychiatrists have developed a variety of ways to integrate mental health services with medical practice. For many years the Integration Clinic at Beth Israel Hospital [5], staffed by psychiatric residents three half days a week, provided support for the medical staff, specialized treatment, evaluation and screening of reluctant or apprehensive medical patients. In the Tumor Clinic and the Home Care Service of the same hospital, a part-time psychiatrist worked closely with physicians, and was able to teach the principles of medical psychology in the care of severely ill and dying patients [ 6 ] . Fox [7] describes his experience in the general medical clinics at the Peter Bent Brigham Hospital where a psychiatrist is included on each part-time physician team. In their review of forty-four OEO-funded health centers, Scherl and English [8] describe health care teams with social workers to which psychiatrists are available for consultation and direct service. At the Martin Luther King Center [9] a psychiatrist or a psychologist attends team meetings and participates in clinic sessions in which patients are interviewed in the presence of the team. Fink et al. [lo] report that requests for consultation increased when psychiatric treatment was offered as a service in addition to consultation and diagnostic services alone at the Health Insurance Plan of Greater New York. Physicians gained a more realistic idea of what can and cannot be accomplished by psychiatric care and became more willing to carry patients themselves. Stratas and Cathell [ll] stress the importance of working in the physicians’ own setting and describe the experience of a psychiatrist who made regular trips to physicians’ offices in rural North Carolina. Fifty-eight out of sixty-four physicians effectively managed the aftercare of formerly psychiatrically hospitalized patients. Consultation alone, however, provides insufficient concrete evidence about the potential contribution of psychiatry to busy medical practitioners, nor does the consultant grow to appreciate fully the extent of the problems with which the medical staff struggle. Psychiatrists can take another approach by offering seminars in medical psychology, with either a short-term didactic or a long-term supervisory orientation [12-141. These seminars have been found to be quite successful in changing doctors’ attitudes and practices. But few physicians leave their own practices to attend. In their description of their own experience with these seminars, Zabarenko, Pittenger and Zabarenko [15] outline the characteristics of the participating and “control” physicians and their practices, and report a favorable effect of the seminars on physicians’ behavior. Prepaid group practices, such as the Harvard Community Health Plan, offer the opportunity for psychiatrists to work with and teach medical staff. Although the existence of separate departments presents some barriers to effective interaction, mutual work, teaching, consultation and therapy, all form
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an integral part of general health care in their setting [ 161 . Coleman and Patrick [ 171 describe the direct integration of social workers, clinical psychologist, and psychiatric nurse as members of health care teams in the Community Health Center Plan of New Haven, a prepaid plan with 17,000 enrollees. At a cost of $0.55 per enrollee per month, the enrollees can receive brief psychotherapy from these mental health workers, with the psychiatrist serving as director and consultant. The psychiatrist’s role is not defined further. Borus et al. [18, 191 describe four interactional models between Community Mental Health Centers, Neighborhood Mental Health Systems and nineteen Boston Neighborhood Health Centers: 1. a “joint endeavor” model in which mental health staff are located at least part-time in the neighborhood health center and are paid from several sources, 2. an “Autonomous Neighborhood Health Center Model” in which the mental health program is totally funded and run by the health center, 3. a “Community Mental Health Center Outpost Model” in which mental health staff are paid by the Community Mental Health Center and assigned to work in the neighborhood health center, and 4. a “consultative model.” Morrill [20] suggests that a large part of mental health services should be integrated clinically, administratively, and financially into comprehensive health care. He also concludes that medical care providers cannot readily use part-time consultation or full-time but separate services. Lipowski [21, 221 advocates that “the primary basis of operation for psychiatric, or mental health, consultants should be the health care system alongside other health professionals.” Although such consultation-liaison psychiatrists provide valuable links between psychiatry and medicine and many are actively involved in research and teaching in the psychosocial aspects of primary health care, they are not usually an integral and functional part of the comprehensive health care system itself. Fink and Oken [23] present evidence that psychiatry is a primary care specialty providing first contact medicine, longitudinal responsibility, and an integrationist function for the patient. Lazerson [24,25] describes an exclusively teaching role for a consultation-liaison psychiatrist in a Primary health care setting. This paper describes one psychiatrist’s experience in providing psychiatric services as an integral part of a primary health care system in a hospital setting.
The Setting The Beth Israel Ambulatory Care Center [26] consists of five service delivery units: internal medicine, pediatrics, obstetrics-gynecology , medical
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walk-in and home care. Its establishment on October 1, 1972, with its own cost-revenue center and a full-time staff of about fifty represented a complete reorganization of the existing general out-patient services. Patients seeking medical care are now served by small teams consisting of a physician, nursepractitioner, social worker, receptionist, nutritionist and health assistant. House staff and medical students are regularly assigned to work with them. These eight teams receive clinical and administrative support from a seven member “core team” made up of the Medical Director, Administrator, Assistant Administrator, Psychiatrist, Research Adviser, Social Service Coordinator for Ambulatory Care, and the Assistant Director of Nursing for Ambulatory Care. The Center’s volume is about 50,000 visits per year. The psychiatrist is paid by the Ambulatory Care Center, where his office is located. He shares corridors, waiting room, and coffee pot with the medical staff and works with them in a wide variety of clinical, teaching and administrative ways. He spends half-time in direct, reimbursable patient encounters, and half-time in providing indirect services: consultation, staff education, clinical conferences, joint interviews, home visits, emergencies, administration, planning and research. By virtue of the economic, geographic, academic, administrative and patient care involvement in the Ambulatory Care Center, this psychiatrist’s role is different from that of the traditional consultationliaison psychiatrist. Since his patients already have a physician or nurse as their primary health care provider, he is not a primary care specialist as described by Fink and Oken [23].
The Building of Relationships Starting with the basic premise of full-time economic and geographic integration in the primary health care setting, the psychiatrist’s role has evolved through stages resembling several of the models described above. This evolution was brought about by relationship building and role negotiations with other members of the center’s staff, and by an ongoing process of mutual education. In the beginning, the Center’s staff members and administrators were preoccupied with the tensions produced by the reorganization of services and the formation of interdisciplinary health-care teams. Furthermore, they were unfamiliar with psychiatric practice and uneasy about the presence of a fulltime psychiatrist in their midst. At first, both the medical director and the psychiatrist thought the most desirable role would be that of consultant t o the staff. The psychiatrist would serve the patients mainly by supporting and improving the staffs mental health skills. This proved unacceptable to the physicians, who wanted the psychiatrist to take their difficult and “crazy” patients off their hands. The medical director served as an important mediator in clarifying the psychiatrist’s role with the physicians. The director reviewed
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with the psychiatrist the needs and pressures of primary medical practice. He encouraged the physicians to work with the psychiatrist on specific cases and to modify their expectations of instant, magical solutions for psychiatric problems. Discussion of the use of psychoactive drugs provided a good springboard for initiating communication and mutual respect. Specific plans were laid down for the psychiatrist to see some of the Center’s patients directly, and a mechanism for the scheduling and billing of psychiatric service was established. The psychiatrist asked to participate with the Center’s other physicians in a biweekly peer review conference. In this way, routine psychiatric practice was made more visible and familiar to the Center’s nonpsychiatrist physician staff. The mutual education of administrator and psychiatrist began at the time of the first major budget and staffing review. A delay of six to seven months between billing and collection had produced a falsely low income figure for psychiatric services. This reinforced the common impression among hospital administrators that mental health services are poor income producers and are, therefore, impractical. Fortunately, the psychiatrist had kept his own weekly list of patients seen, charges rendered and income expected. Thus, within a day, he was able to place a graphic summary of accounts on the administrator’s desk. The ensuing discussion served to solidify the administration’s commitment to the psychiatrist, and to expand the psychiatrist’s understanding of administrative pressures. The building of good relationships with the Center’s ten social workers was complicated on both sides by the competitiveness that comes from having similar professional backgrounds, and from uncertainty in the perceptions of other staff members. Concrete services such as helping patients with welfare, public assistance, housing and the like were clearly accepted as social services. When psychosis, severe suicide risk, psychoactive medication, hospitalization and complicated diagnostic issues were at question, the staff turned to the psychiatrist. However, in the broad area of psychiatric diagnosis, patient management, counseling and psychotherapy, many of the social workers had training quite similar to that of the psychiatrist, and the non-mental health staff was initially confused about when to call on whom for what. The relationship between psychiatrist and social worker was further complicated by an administrative difference between this medical setting and the usual mental health setting in which social workers come under the administrative and supervisory responsibilities of the psychiatrist. In the Ambulatory Care Center the social workers are responsible to the social service coordinator, who in turn reports to the medical director and the administrator. The psychiatrist had to establish co-worker relationships with each social worker by meshing his areas of clinical expertise with their particular interests and skills. A relationship was worked out with the coordinator of social services in which she bears the administrative and supervisory responsibility for the social
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workers, and the psychiatrist takes responsibility for consultation and back-up services to them. This arrangement has enabled social workers and their medical teams to treat very difficult patients, has resulted in a rewarding variety of available psychotherapeutic skills, and has given the psychiatrist time and freedom to relate uniformly and effectively with everyone on the Center’s staff. In this primary care setting, the psychiatrist has learned to appreciate the advantages of freedom from administrative responsibility for large numbers of mental health professionals. A role with the nurses also evolved from shared work with patients. Since the Center has no psychiatric nurses, the nursing staff at first turned to social workers for assistance with their patients’ emotional problems. Gradually, they began t o ask the psychiatrist as well for evaluations, treatment suggestions, and help in understanding their own feelings about patients. A paper written by one of the nurse-practitioners and the psychiatrist about the management of a patient was a most effective way to establish mutual respect [27]. Through their contacts with the psychiatrist and the social workers, nurses have learned enough about psychiatric management to function effectively with severely disturbed patients. Often the nurse is the provider to whom a mentally ill person relates the best. Because of their rapport with patients, nurses have been effective in preparing them for psychiatric consultation. Patients coming to the Ambulatory Care Center identify their main problems as physical. A large percentage of the patients are over sixty-five and tend to reject the idea that some of what they feel may be related to psychological conflicts. Many psychotic and borderline patients flatly refuse involvement with the mental health staff and can completely disrupt the medical system. Coping with these patients depends upon teaching staff how to recognize and contain their own feelings, to communicate quickly with each other and to set consistent limits. The psychiatrist was more readily accepted by patients as a working member of the medical team when introduced by their primary health care provider in the context of this kind of collaborative effort. Because of his involvement in a special kind of practice, the psychiatrist in primary health care can easily become isolated from his psychiatric colleagues. Even though the psychiatrist in the Beth Israel Ambulatory Care Center is a member of the hospital’s academic Department of Psychiatry, special efforts had to be made to build relationships in the department. Guidelines had to be established for help with emergencies and with hospitalizations. It was particularly important to arrange for regular consultation with the department’s Director of Adult Services. Understanding and communication improved even further when the psychiatrist worked with various members of the Department and the primary care center to secure federal funding for the training of a psychiatric fellow for future work in primary health care.
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Present Activities The psychiatrist’s present role is the result of the relationships he developed with staff and patients. The way in which the primary health care staff is organized for patient care and teaching provides the structure in which he works. Direct patient care, the traditional work of the psychiatrist, continues to lend validity to and earn respect for the psychiatrist. Since the medical and social work staff know all of his patients, his psychiatric work becomes highly visible and interesting to them. During the year May 1, 1974 to May 1, 1975, the psychiatrist completed 900 patient encounters. Three hundred were for group therapy. Of the 600 individual encounters 270 were for long-term treatment, 120 for short-term interventions, 130 for medication and support, and eighty for evaluation. Of the 220 patients represented by this sample, seventy-five were considered neurotic, fifty-five psychotic, eighty character disorders and ten borderline. More than half of these patients had some form of third-party insurance coverage although many were self-paying. The money generated by these encounters adequately paid for the psychiatrist’s direct service time. The revenue and grants for teaching and research covered his full-time salary. A group therapy program, developed with one of the social workers, is one of the primary ways in which direct psychiatric service is made available t o the Center’s patients. There are groups for patients with similar medical problems such as chronic lung disease, heart disease, obesity, and severe physical handicaps. Other groups are organized around life-stage problems : depression in young adults; coping with middle age; support for the elderly; single motherhood; and becoming a father for the first time. A brief seminar on the elements of group process is given monthly by the psychiatrist to medical students and staff, and supervision is offered to staff members wishing to develop their skills in work with groups. Psychiatric evaluations are often requested by physicians, nurses, and social workers. Because of their exposure to psychiatric teaching, they usually form their own impression before asking for special help. In emergencies, the psychiatrist is asked to evaluate further the degree of psychosis, suicide Potential, danger to others, need for psychoactive medication, or hospitalization. Whenever possible, patients in need of hospitalization are admitted to the fourteen-bed psychiatric inpatient service so that the primary health care staff can more easily follow their progress. Psychiatric hospitalization has had to be arranged for one to five patients per month. In addition to evaluating the patients in a medical examining room or on one of the medical inpatient services, the psychiatrist goes to the patients’ homes when necessary. Using the problem-oriented format familiar to other providers, the psychiatrist writes directly in the patient’s medical record. In these brief, accessible
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notes, he conveys the essence of the problem in simple nonPsYchiatric language, and lists concrete suggestions for management. He has also altered his clinical practice to allow for brief interruptions when important. He carries a ‘‘beeper’’ with him at all times. Knowing this enables staff members to contain their anxiety and to manage well until the psychiatrist is free to consult with them directly. Once a week each health care team meets to review interesting and difficult cases. The psychiatrist goes to as many of these meetings as possible and is often specifically requested by a team to attend. This enables him to hear about a large number of patients and to keep in touch with the details of medical practice on each team. He is asked to comment on the psychiatric aspects of patient care, to offer management suggestions, t o speak briefly about a clinical syndrome or a particular psychoactive drug, or to help the staff understand, contain and use their own feelings for a patient’s benefit. For example, the staff has learned that anger directed toward a patient may be a clue to significant psychopathology in the patient rather than simply indicating willful unpleasantness [27]. One team became furious at a chronically psychotic woman with diabetes and liver disease who was alternately seductive, psychotic, in pain, or overdosed when she came in to see the physician and nurse. After her admission to the psychiatric ward, the team worked out a plan: the social worker would see her weekly for an hour; the psychiatrist made himself available for crises and counseling with family members; the nurse was to dispense medication weekly; and the physician arranged regular visits for medical follow-up. This division of labor among clearly identified team members has facilitated the management of many difficult patients who would otherwise have worn out a single provider. Providers have also learned who may and who may not improve with psychiatric treatment. In the situation just described, they no longer expect a complete cure of the patient’s psychopathology and are able to give their energy to a management plan that contains the situation well through years of ups and downs. Social service rounds are held weekly in both the medical and the obstetricsgynecology units. In this major staff educational effort, the psychiatrist assists in the presentation of cases and in the review of topics of social and psychological interest. These sessions present an opportunity to demonstrate and share knowledge, and to demythologize the process of psychotherapy. For example, when the psychiatrist discussed the young adults group after a year of treatment, the medical and nursing staff heard concretely how their patients had benefitted from this form of psychotherapy. Videotaped interviews are shown and discussed. In this way, the staff learns the specific differences between and the indications for the various types of psychotherapy. Teaching is an important part of the Ambulatory Care Center’s activities. After medical interns, residents and the supervising health care team see
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I 237
patients in the afternoon, they meet to review their work. At these meetings a social worker or the psychiatrist discusses the psychiatric aspects of particular cases. Two medical students a month work full-time as clinical clerks in the Center and participate in all teaching activities. The Center now has four primary care residents in training. The psychiatrist meets with them weekly for an hour to review clinical situations, to interview patients and to present didactic material. Each primary-care resident is expected to treat at least one patient in short-term psychotherapy in order to experience one form of psychotherapy first hand with hour by hour supervision by the mental health staff. As a member of the administrative “core” staff, the psychiatrist participates in long range planning, funding, research activities and priority setting for the Ambulatory Care Center. What has been described is a comprehensive role for a staff psychiatrist in a primary health care setting. He provides direct care as an on-line co-worker and shares the work of operating an integrated comprehensive mental health center. He enhances and supports the development of psychiatric skills through teaching, consultation, and general availability on a full-time, long-term basis. The following case illustrates some of the ways in which the psychiatrist works with patients and staff. A young couple, both chronically psychotic and refusing psychoactive medication, were referred to the Center by their private psychiatrist for prenatal care. After their first visit, the social worker on their obstetrical health-care team asked the Center’s psychiatrist to see them with her. He worked with the team to develop a management plan and the medical and nursing staff admirably contained the couple’s irrational fears and paranoia. Although delivery was hardly uneventful, the situation remained under control until the day the couple took the baby home. Then the father became disorganized and delusional, refused to accompany the wife and child home and said that he would not let them into their apartment in a town at some distance from the hospital. They all left in a flurry of confusion, only to reappear hours later in the emergency room. The social worker made arrangements for the mother and child to spend the night elsewhere, and the psychiatrist was able to persuade the father to take antipsychotic medication for the first time. The father came in the next day considerably more organized, and the team judged that the family could go home. The Visiting Nurse Association was to make daily visits, and the crisis team in their mental health catchment area was notified. A few days later all of the professionals involved were convened. The conference allowed them to share their anxieties and concern about the welfare of the child. The psychiatrist, acting as an administrator, said that he would take the responsibility for initiating a Care and Protection Order, if necessary, and went the next morning with the visiting nurse to investigate the home situation.
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Surprisingly, the baby was found to be well cared for in a fairly wellorganized apartment. The professionals, however, were predictably still at loose ends. The psychiatrist spent the rest of the morning at the local Mental Health Clinic and at the Visiting Nurse Association’s office. Misunderstanding: were cleared up and the way was paved for their private psychiatrist to resum treatment and to work with local professionals for continuing care of the family. This case illustrates the multiplicity of tasks and roles required of the psychiatrist in primary health care. He must follow through in a number of different clinical and community settings. This represented another important step toward his acceptance as a useful member of the Ambulatory Care CenteI staff. Summary For the psychiatrist to work successfully in a primary health-care setting, he has to develop a style of relating to other professionals that is neither rigid nor overly compliant, but one flexible and firm in illustrating the uses of interactional therapy and psychological concepts in the diagnosis and treatment of medical illness [28, 291. A stable, well-organized health-care setting with a medical director willing to support the role of the psychiatrist is essential. The psychiatrist needs to take pains t o familiarize himself with the pressures and demands of medical practice and to demonstrate his usefulness by working with patients. Familiarity with the broad range of psychoactive medication use is an excellent entree. Conditions for clinical practice should include physical location in the health care setting and arrangements for occasional interruption. The psychiatrist must know the pressures placed on his administrators and keep accurate records of his activities. He should participate in administrative planning and research. The psychiatrist who works in nonpsychiatric systems has to keep his lines of communication open to psychiatric colleagues as well. A working affiliation with a department of psychiatry in the same institution or nearby is essential. By working in a health-care setting the psychiatrist brings his skills to patients who often resist mental health care even when it is badly needed. Having established his usefulness by visibility and example, he is in a unique position to teach the principles of medical psychology to other providers. It is recommended that positions similar to his become an integral component of medical settings and future systems for the delivery of mental health services. REFERENCES 1. M. A. Stewart, F. Drake, G. Winokur, et al., Depression Among Medically I11 Patients, Dis. Nerv. Syst., 26, pp. 479-484, 1965.
A PSYCHIATRIST'S EXPERIENCE IN PRIMARY H E A L T H C A R E I 239
2. N. A. Cummings and W. Follette, Psychiatric Services and Medical Utilization in a Prepaid Health Plan Setting, 11, Med. Care, 6, pp. 31-41, 1968. 3. M. R. Eastwood, The Relation Between Physical and Mental Illness, University of Toronto, Buffalo, N.Y., 1975. 4. W. Follette and N. A. Cummings, Psychiatric Services and Medical Utilization in a Prepaid Health Plan Setting, I, Med. Care, 5 , pp. 25-35, 1967. 5 . D. R. Lipsitt, Integration Clinic: An Approach t o the Teaching and Practice of Medical Psychology in an Outpatient Setting, in Psychiatry and Medical Practice in a General Hospital, N. E. Zinberg, (ed.), International Universities Press, New York, pp. 231-249, 1964. 6. E. C. Payne, Teaching Medical Psychotherapy in Special Clinical Settings, in Psychiatry and Medical Practice in a General Hospital, N. E. Zinberg, (ed.), International Universities Press, New York, pp. 135-1 68, 1964. 7. H. M. Fox, Psychiatric Consultation in General Medical Clinics, a n Experiment in Postgraduate Education, J. Amer. Med. Assoc., 185, pp. 999-1003, 1963. 8. D. J. Scherl and J. T. English, Community Mental Health and Comprehensive Health Service Programs for the Poor, Amer. J. Psychiat., 125, pp. 16661674, 1969. 9. E. L. Lowenkopf and I. Zwerling, Psychiatric Services in a Neighborhood Health Center,Amer. J. Psychiat., 127, pp. 916-920, 1971. 10. R. Fink, S. S. Goldensohn, S. Shapiro, et al., Changes in Family Doctors' Services for Emotional Disorders After Addition of Psychiatric Treatment t o a Prepaid Group Practice Program, Med. Care, 7, pp. 209-224, 1966. 11. N. E. Stratas and J . L. Cathell, Psychiatric Consultation with Community Physicians, Hosp. Community Psychiat., 17, pp. 202-204, 1966. 12. A. J. Barthold, The Physician Education Project'of the American Psychiatric Association, Medical Meetings Magazine, United Business Publications, 1974. 13. M. Balint, The Doctor, His Patient and The Illness, International Universities Press, New York, 1964. 14. M. Balint and E. Balint, Psychotherapeutic Techniques in Medicine, Tavistock Publications, London, 1961. 15. L. Zabarenko, R. A. Pittenger and R. N. Zabarenko, Primary Medical Practice, a Psychiatric Evaluation, Warren H. Green, St. Louis, 1969. 16. M. J. Bennett, Personal Communication. 17. J . V. Coleman and D. L. Patrick, Integrating Mental Health Services into Primary Medical Care, Med. Care, 14, pp. 654-661, 1976. 18. J. F. Borus, L. A. Janowitch, F. Kieffer, et al., The Coordination of Mental Health Services at the Neighborhood Level, Amer. J. Psychiat., 132, pp. 1177-1181, 1975. 19. J. F. Borus, L. A. Janowitch, F. Kieffer, et al., Neighborhood Health Centers: The Mental Health Delivery System of the Future?, unpublished manuscript, presented at the American Public Health Association meeting, New Orleans, La., October 1974. 20. R. G. Morrill, A New Mental Health Service Model for the Comprehensive Neighborhood Health Center, Amer. J. Pub. Hlth., 62, pp. 1108-1 11 1, 1972. 21. 2. J . Lipowski, Consultation-Liaison Psychiatry: An Overview, Amer. J. Psychiat., 131, pp. 623-630, 1974.
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22. Z. J. Lipowski, Consultation-Liaison Psychiatry: Past, Present, and Future, in Consultation-Liaison Psychiatry, R. 0 . Pasnau, (ed.), Grune and Stratton, New York, pp. 1-28, 1975. 23. P. J. Fink and D. Oken, The Role of Psychiatry as a Primary Care Specialty, Arch. Gen. Psychiat., 33, pp. 998-1003, 1976. 24. A. M. Lazerson, The Psychiatrist in Primary Medical Care Training: A Solution to the Mind-Body Dichotomy?, Amer. J. Psychiat., 133, pp. 964966,1976. 25. A. M. Lazerson, The Psychiatrist as Teacher in Primary Care Residency Training: The First Year, Int. J. Psychiat. in Med., 7, pp. 165-178, 1976-77. 26. A. A. Berarducci, T. L. Delbanco and M. T. Rabkin, The Teaching Hospital and Primary Care: Closing Down the Clinics, N e w Engl. J . Med., 292, pp. 615-620, 1975. 27. K . A. Gruber and H. E. Schniewind, Letting Anger Work for You, Amer. J. Nurs., 76, pp. 1450-1452, 1976. 28. H. S. Abram, Interpersonal Aspects of Psychiatric Consultants in a General Hospital, Int. J. Psychiat. in Med., 2, pp. 321-326, 1971. 29. R. J . Kahana and G. L. Bibring, Personality Types in Medical Management, in Psychiatry and Medical Practice in a General Hospital, N. E. Zinberg, (ed.), International Universities Press, New York, pp. 108-1 23, 1964.
Direct reprint requests to: Henry E. Schniewind, Jr., M.D. Beth Israel Ambulatory Care Center Beth Israel Hospital 330 Brookline Avenue Boston, Massachusetts 022 15
