Letters to the Editor
Re: Strategies of Collaboration Between General Practitioners and Psychiatrists: a Survey of Practitioners’ Opinions and Characteristics
Dear Editor:
Congratulations to Lucena and others for their scholarly survey of practitioners’ opinions on collaboration between general practitioners (GPs) and psychiatrists (1). The varied acceptance of different degrees of collaboration reported is in keeping with our experience. In 2 initiatives, GPs have made limited use of opportunities for collaborative care with psychiatrists. On both occasions, this was contrary to GP-stated perceived needs.
In 1997, ACCESS, a national continuing medical education (CME) program on psychosis management for primary care physicians, was delivered (2). The needs assessment identified GPs’ perceived lack of access to, and collaboration with, psychiatrists as a primary clinical and (or) educational need. The program’s educational design attempted to address this need. Groups of 8 to 10 GPs and a psychiatrist consultant facilitator were formed. They met locally in their communities for 2 separate case-based educational sessions. Between sessions, the GPs had telephone access to their psychiatrist consultant. This was included as part of the educational program to foster collaboration and access to psychiatrists, to specifically meet the identified need. Funding for psychiatrist availability was provided. Telephone logbooks for documentation were developed, and interactions were tracked. However, the telephone contacts were rarely if ever used. Most psychiatrists received no calls from the GPs.
A second clinical experience demonstrated a similar unexpected outcome (3). In 1996, GPs at North York General Hospital expressed dissatisfaction and frustration with a poor, noncollaborative relationship and a lack of access to psychiatry. In response, the hospital department of psychiatry implemented a Primary Care Psychiatric Outreach Program. If requested by the GP, a psychiatrist would provide timely on-site collaborative clinical educational consultations in the GP’s office. This almost immediately satisfied the GP outcry for improved access and markedly improved the psychiatry–family practice department relations. Still, the Primary Care Psychiatric Outreach Program was and continues to be rarely, if ever, used. Despite having 381 GPs on staff at our hospital, we average 1 or 2 requests each month from the same few physicians. Meanwhile, our traditional outpatient clinic remains extremely busy, with approximately 120 new GP referrals each month.
Models of collaborative and shared mental health care have many proposed benefits (4). Our benevolent, liberal-minded sentiments toward collaborative care had us hopeful that collaboration would be eagerly embraced and appreciated. In hindsight, this was a naïve, overly simplistic vision for mental health delivery. The survey by Lucena and others demonstrates that issues of collaborative care are more complex. Many practitioners are uninterested in close collaboration, including GPs. Lucena and others’ work adds important information at a time when delivery systems and third-party payers are struggling with ways to better provide mental health care to their populations.
References
1. Lucena R, Lesage A, Elie R, Lamontagne Y, Corbiere M. Strategies of collaboration between general practitioners and psychiatrists: a survey of practitioners’ opinions and characteristics. Can J Psychiatry 2002;47:750-8.
2. Ungar TE, Remington G, Keith R. ACCESS: a National Program of Education and Consultation in Psychiatry. San Diego (CA): American College of Continuing Medical Education. Poster Presentation. January 29, 1998.
3. Ungar TE, Jarmain S. Shared mental health care: a collaborative consultation relationship. The North York General Hospital Experience. Hospital Quarterly. 1999;3(2):34–40.
4. Kates N, Craven M, Bishop J, Clinton T, Kraftcheck D, LeClair K, and others. Shared mental health care in Canada. Ottawa (ON); Canadian Psychiatric Association and The College of Family physicians of Canada; October 1997. Position Paper 1997–38. 12 p. Available from: www.cpa-apc.org.
Thomas E Ungar, MD, MEd, CCFP, FRCPC, ABPN
Toronto, Ontario
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