Child and adolescent psychiatry’s Child and adolescent psychiatry’s role in a professional dilemmarole in a professional dilemma

Bela Sood, M.D. Bela Sood, M.D. Virginia Commonwealth UniversityVirginia Commonwealth University

Douglas Robbins, M.D.Douglas Robbins, M.D.Maine Medical CenterMaine Medical Center

Co-Chairs, Clinical Practice Committee, SPCAPCo-Chairs, Clinical Practice Committee, SPCAP

MCO’s/ Litigation & other MCO’s/ Litigation & other

Monsters:Monsters: Setting Expectations for Professional Setting Expectations for Professional

& Ethical Clinical Practice& Ethical Clinical Practice

The practice of modern medicine…..disparities, The practice of modern medicine…..disparities, dependence on market forces to transform health dependence on market forces to transform health care systems, tempts physicians to forsake their care systems, tempts physicians to forsake their traditional commitment to the primacy of patient traditional commitment to the primacy of patient interests interests

To maintain the fidelity of our contract with To maintain the fidelity of our contract with society : have to reaffirm our dedication to the society : have to reaffirm our dedication to the principles of professionalism for not just our principles of professionalism for not just our individual patient but to the health care system individual patient but to the health care system as a whole and thus improve health care for as a whole and thus improve health care for society overall..society overall..

Medicine’s contract with society: Medicine’s contract with society: pt interests above those of the physician: pt interests above those of the physician:

market forces must not impede thismarket forces must not impede this Pts autonomy: empower to make the right Pts autonomy: empower to make the right

decision with shared knowledge, honesty decision with shared knowledge, honesty about medical errorsabout medical errors

Principles of social justice: fair distribution Principles of social justice: fair distribution of health care resources, (reducing of health care resources, (reducing discrimination)discrimination)

Commitment to improving quality of care, Commitment to improving quality of care, improving access to careimproving access to care

Commitment to setting competence and Commitment to setting competence and integrity standards (life long learning), integrity standards (life long learning), expert advice on maters of healthexpert advice on maters of health

Commitment to the integrity of scientific Commitment to the integrity of scientific knowledge that is based on knowledge that is based on evidence/experienceevidence/experience

Commitment to honor the relationship by Commitment to honor the relationship by not exploiting the dependent vulnerable not exploiting the dependent vulnerable position for the patient for financial, sexual position for the patient for financial, sexual or other personal reasons or other personal reasons

Commitment for managing conflict of Commitment for managing conflict of interest in order to be trustedinterest in order to be trusted

Self regulation, remediation and discipline Self regulation, remediation and discipline of members who do not meet professional of members who do not meet professional standards.standards.

The ethics and professional The ethics and professional standards of practice as we define it standards of practice as we define it as a professionas a profession

The external elements that impact The external elements that impact our ability to deliver care ethically our ability to deliver care ethically and professionally and professionally

Clinical work….and Academia?Clinical work….and Academia?

Financial viability?Financial viability? Keeping up with the competition?Keeping up with the competition? Outsourcing or developing nicheOutsourcing or developing niche All things to everyone or “boutique” All things to everyone or “boutique”

operationoperation

* Central to mission of the operation* Central to mission of the operation

Erosion of Life as we knew itErosion of Life as we knew it

Time constraintsTime constraints

Man Power shortageMan Power shortage

Reimbursement Reimbursement

Mismatch between expectations and Mismatch between expectations and “delivery of goods”“delivery of goods”

Role of TechnologyRole of Technology

(New) Knowledge used as a “stick” (New) Knowledge used as a “stick” by consumers and “gatekeepers” by consumers and “gatekeepers”

Challenges:Challenges:

How to…..stay aheadHow to…..stay ahead

avoid defensivenessavoid defensiveness

set standards for trainees set standards for trainees

Role of the child psychiatristRole of the child psychiatrist

““Pill Pusher”Pill Pusher” ““Holistic Treator”Holistic Treator” ““Psychotherapist”Psychotherapist” ““Diagnostician”Diagnostician” Or Or All to someAll to some Or some to all Or some to all

The brave new world….The brave new world….

The emergence of managed care The emergence of managed care organizationsorganizations

The evolution of MCO’sThe evolution of MCO’s The role of physicians The role of physicians The role of this middle manThe role of this middle man ““To play or not to play” is the To play or not to play” is the

questionquestion

Anti trust and health care laws Anti trust and health care laws

Managed Care OrganizationsManaged Care Organizations

Challenges:Challenges: How and when enough is enough?How and when enough is enough? How to impact practices of MCO’sHow to impact practices of MCO’s How can our colleagues who serve as How can our colleagues who serve as

medical directors impact policy for MCO’s?medical directors impact policy for MCO’s? Role of The Insurance Commissioner and Role of The Insurance Commissioner and

SECSEC Role of antitrust and health care law Role of antitrust and health care law

LitigationLitigation

Not a high risk specialtyNot a high risk specialty ButBut the specter of metabolic syndromes and the specter of metabolic syndromes and

“black box warnings”….”drug drug “black box warnings”….”drug drug interactionsinteractions

The potential for violenceThe potential for violence The appearance of “inaction”The appearance of “inaction” The “relationship” problems with families/ The “relationship” problems with families/

other disciplinesother disciplines

Mitigation of RiskMitigation of Risk

A focus on understanding the risks A focus on understanding the risks and why they existand why they exist

Developing a rationale for why we do Developing a rationale for why we do what we dowhat we do

Helping trainees develop rational Helping trainees develop rational logical paradigms for clinical care, logical paradigms for clinical care, skills for clear articulation skills for clear articulation

Focus on relationships, listening with Focus on relationships, listening with the “third ear” the “third ear”

Patient abandonmentPatient abandonment Inappropriate behavior with Inappropriate behavior with

pt/colleague…. example pt/colleague…. example Inappropriate management of patientInappropriate management of patient How does termination occur: “firing and How does termination occur: “firing and

hiring”hiring” Do doctors “tell” on doctors or “guild” Do doctors “tell” on doctors or “guild”

protection….. physician heal thyselfprotection….. physician heal thyself

When in doubt is there help?When in doubt is there help?

Supervision with colleagueSupervision with colleague Professionalism committees set Professionalism committees set

expectations at school level: rules/ expectations at school level: rules/ behavior behavior

Ethics in clinical practice: university Ethics in clinical practice: university risk management/legal team risk management/legal team

Ethics committee of AACAPEthics committee of AACAP

Standard for TraineeStandard for Trainee

Challenges:Challenges: Working in a multidisciplinary teamWorking in a multidisciplinary team Espousing a “democratic” decision Espousing a “democratic” decision

making processmaking process Maintaining authentic and safe Maintaining authentic and safe

medical managementmedical management Fine line before Fine line before

“autocratic/respondent superior” role “autocratic/respondent superior” role emerges emerges

Standards of Professional Behavior Standards of Professional Behavior

These standards describe behaviors expected from faculty, housestaff, and students These standards describe behaviors expected from faculty, housestaff, and students in the School of Medicine: in the School of Medicine:

Recognize their positions as role models for other members of the health care team. 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, Carry out academic, clinical and research responsibilities in a conscientious manner,

make every effort to exceed expectations and make a commitment to life-long make every effort to exceed expectations and make a commitment to life-long learning. learning.

Treat patients, faculty, housestaff and students with humanism and sensitivity to Treat patients, faculty, housestaff and students with humanism and sensitivity to diversity in characteristics such as culture, age, gender, disability, social and diversity in characteristics such as culture, age, gender, disability, social and economic status, sexual orientation, etc. without discrimination, bias or harassment. economic status, sexual orientation, etc. without discrimination, bias or harassment.

Maintain patient confidentiality. Maintain patient confidentiality. Be respectful of the privacy of all members of the medical campus community and Be respectful of the privacy of all members of the medical campus community and

avoid promoting gossip and rumor. avoid promoting gossip and rumor. Interact with all other members of the health care team in a helpful and supportive 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 fashion without arrogance and with respect and recognition of the roles played by each individual. each individual.

Provide help or seek assistance for any member of the health care team who is 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. 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 Be mindful of the limits of one's knowledge and abilities and seek help from others whenever appropriate. whenever appropriate.

Abide by accepted ethical standards in the scholarship, research and standards of Abide by accepted ethical standards in the scholarship, research and standards of patient care. patient care.

Abide by the guidelines of the Abide by the guidelines of the VCU Honor SystemVCU Honor System. .

These standards were proposed by the These standards were proposed by the Professionalism CommitteeProfessionalism Committee and adopted by and adopted by the School of Medicine in September 2001. The standards are also available in print the School of Medicine in September 2001. The standards are also available in print in the form of in the form of pocket cardspocket cards and and postersposters. Contact Debbie Stewart (804-828-6591, . Contact Debbie Stewart (804-828-6591, dstewart@vcu.edudstewart@vcu.edu) for copies. ) for copies.

ProfessionalismProfessionalism

TransparencyTransparency HonestyHonesty AccountabilityAccountability Unafraid to get the “job” done, yet Unafraid to get the “job” done, yet

not seen as “on a power trip” not seen as “on a power trip” Emotional intelligence to determine Emotional intelligence to determine

“timing” “timing” The role of “mezzanine” people The role of “mezzanine” people

EthicsEthics

When to say no to patient care?When to say no to patient care? Evidence based practice vs. InstinctEvidence based practice vs. Instinct The ideal and the realThe ideal and the real

Clear rationale: 3.5 year old….Clear rationale: 3.5 year old….

Audience input….Audience input….

Challenges in implementing Challenges in implementing Evidence-Based Practices:Evidence-Based Practices:

Child and Adolescent Child and Adolescent Psychiatry’s role in this Psychiatry’s role in this professional dilemmaprofessional dilemma

DilemmasDilemmas Child and adolescent psychosocial treatment often has Child and adolescent psychosocial treatment often has

limited effect.limited effect. (E.g. Weisz JR, 2004)(E.g. Weisz JR, 2004)• The public health impact of what we do is insufficient.The public health impact of what we do is insufficient.

Child Psychiatry has a significant array of EBPs, but they Child Psychiatry has a significant array of EBPs, but they are rarely really implemented.are rarely really implemented.

We are often reinforced for continuing previous patterns of We are often reinforced for continuing previous patterns of practice. practice. • Reimbursement patterns, Medicaid and insurance rules Reimbursement patterns, Medicaid and insurance rules

continue the status quocontinue the status quo

The Feinstein Challenge: We train residents in The Feinstein Challenge: We train residents in development and the art and science of treatment, and development and the art and science of treatment, and then their practices involve primarily medication then their practices involve primarily medication management. Is this the role we intend for them?management. Is this the role we intend for them?• SPCAP 2007SPCAP 2007

Barriers to implementing EBPsBarriers to implementing EBPs

1. 1. Limited applicability of the evidence to clinic Limited applicability of the evidence to clinic populationspopulations

2. Costs of implementation 2. Costs of implementation

3. Clinicians’ discomfort with EBTs 3. Clinicians’ discomfort with EBTs

4. 4. Lack of outcome assessment in clinical workLack of outcome assessment in clinical work

5.5. Organizational cultureOrganizational culture

1. Limited applicability of the 1. Limited applicability of the evidence to clinical populationsevidence to clinical populations

Discrepancies between efficacy trials Discrepancies between efficacy trials and effectiveness. and effectiveness.

Heterogeneous clinical populationsHeterogeneous clinical populations• Comorbid disordersComorbid disorders• Social, economic, cultural diversitySocial, economic, cultural diversity

(Hoagwood K, et.al., 2001)(Hoagwood K, et.al., 2001)

Potential Solutions to the limited Potential Solutions to the limited applicabilityapplicability

Common Elements or Modular Common Elements or Modular approach. Menu of components. approach. Menu of components. Matched to individual patient Matched to individual patient characteristicscharacteristics

(Chorpita BF et.al., 2007)(Chorpita BF et.al., 2007)

Evidence-Informed Practice vs. Evidence-Informed Practice vs. Evidence Based PracticeEvidence Based Practice

(Hamilton J, 2005)(Hamilton J, 2005)

2. Costs of implementation2. Costs of implementation

Direct costs of training and supervisionDirect costs of training and supervision

Training time is not reimbursedTraining time is not reimbursed

Some EBPs not reimbursedSome EBPs not reimbursed• Parent Management Training – without patient presentParent Management Training – without patient present• In-home treatmentIn-home treatment• Collaboration with schools and primary careCollaboration with schools and primary care

Administrative time and costsAdministrative time and costs

Costs of outcome assessmentCosts of outcome assessment

Potential solutions - CostPotential solutions - Cost Outcome-based reimbursementOutcome-based reimbursement

• Risk of discouraging treatment of more difficult Risk of discouraging treatment of more difficult patientspatients

Differential reimbursement for clinicians or Differential reimbursement for clinicians or programs using EBPsprograms using EBPs• E.g. adult ACT teams in New York – treatment E.g. adult ACT teams in New York – treatment

fidelity related to ratefidelity related to rate

Case rate reimbursement vs. fee-for-Case rate reimbursement vs. fee-for-serviceservice

3. Psychiatrists’ and clincians’ 3. Psychiatrists’ and clincians’ discomfort with EBPs discomfort with EBPs

Limitations of time for training and Limitations of time for training and supervisionsupervision

Limitations on clinical contact time – Limitations on clinical contact time – Managed careManaged care

Large number of EBPs – too many to learnLarge number of EBPs – too many to learn

Perceptions of rigidity or poor fit with Perceptions of rigidity or poor fit with patientspatients• Comorbid disordersComorbid disorders• Cultural and economic diversityCultural and economic diversity

3.3. Discomfort with EBPs - Discomfort with EBPs - continuedcontinued

Top-down decisions to use EBPsTop-down decisions to use EBPs

Perceptions that EBPs are not neededPerceptions that EBPs are not needed

Factors associated with openness to Factors associated with openness to innovation.innovation.• TemperamentTemperament• Support vs. anxiety, insecurity. Support vs. anxiety, insecurity.

(Aarons GA, (Aarons GA, 2005)2005)

4. Lack of outcome assessment in 4. Lack of outcome assessment in clinical practiceclinical practice

““The Bell Curve” – The Bell Curve” – New YorkerNew Yorker, 12/6/2004, 12/6/2004

Feasibility – Costs, burden to familyFeasibility – Costs, burden to family

Absence of feedback loops for Absence of feedback loops for performance improvementperformance improvement

Potential mis-use of outcome dataPotential mis-use of outcome data• e.g. negative reinforcement for treating e.g. negative reinforcement for treating

difficult patientsdifficult patients

5. Organizational culture5. Organizational culture

Macro-level – Disincentives to innovation. Macro-level – Disincentives to innovation. • Medicaid and insurance rules and practices.Medicaid and insurance rules and practices.

Behavioral expectations and reinforcers. Behavioral expectations and reinforcers. • ““Productivity”Productivity”

Organization’s sense of the public health Organization’s sense of the public health mission, vs. survival mission, vs. survival

(Glisson C, 2007)(Glisson C, 2007)

There’s hope – Initiatives on There’s hope – Initiatives on implementation of EBPsimplementation of EBPs

Federal - NIMH, CMHS, SAMHSA, Other.Federal - NIMH, CMHS, SAMHSA, Other.

State initiativesState initiatives• Colorado, Hawaii, California, Michigan, New York, OhioColorado, Hawaii, California, Michigan, New York, Ohio

(Bruns EJ and Hoagwood KE, JAACAP, April, 2008)(Bruns EJ and Hoagwood KE, JAACAP, April, 2008)

MacArthur FoundationMacArthur Foundation

Annie E. Casey FoundationAnnie E. Casey Foundation

Annenberg (FoundationAnnenberg (Foundation

(Chambers DA et.al., 2005)(Chambers DA et.al., 2005)

Tilting at Windmills?Tilting at Windmills?Advocacy for Evidence-Informed Advocacy for Evidence-Informed

PracticesPractices Individual case reviews with payorsIndividual case reviews with payors

• Refer to Practice Parameters and EBPsRefer to Practice Parameters and EBPs Cost-effectiveness and benefits to clinical Cost-effectiveness and benefits to clinical

organizationsorganizations• Evidence of effectiveness Evidence of effectiveness

Medical-Legal supportMedical-Legal support Role of the AACAPRole of the AACAP The child & adolescent psychiatrist’s role The child & adolescent psychiatrist’s role

as leader of the multidisciplinary teamas leader of the multidisciplinary team

TrainingTraining Development of familiarity and comfort with Development of familiarity and comfort with

outcome assessment as a routine clinical outcome assessment as a routine clinical practice.practice.

Role of the CAP as one who knows what really Role of the CAP as one who knows what really works – whether or not we can do it now.works – whether or not we can do it now.

Maintain a focus on our responsibility to the Maintain a focus on our responsibility to the community. Spokespersons for best practices. community. Spokespersons for best practices.

Role as leader of the multidisciplinary team, Role as leader of the multidisciplinary team, aware of what is evidence-informed.aware of what is evidence-informed.