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The Role of Rural Primary Care Providers
in the Provision of Mental Health Services: Voices from the
Plains
Letter to the Field No.
10
by Jack M. Geller, Ph.D., Marshfield Medical Research
Foundation
Table of Contents
Introduction | Methodology
| Role of Primary Care Providers | General
Competencies | Relationship Between Rural MDs
& MH Professionals | Summation and
Limitations | References
Introduction
It has been twenty years since Regier, Goldberg, and Taube (1978)
coined the phrase the "de facto mental health system," referring to
the provision of mental health services by the general medical
sector. At that time, using epidemiological methods, they estimated
that approximately 60 percent of the total persons affected by mental
disorders sought treatment in a primary care setting. Subsequent
studies have continued to affirm the presence and importance of this
de facto system (U.S. Department of Health and Human Services, 1984;
National Rural Health Association [NRHA], 1992; Regier, Boyd,
& Burke, 1988; U.S. Congress, 1990).
Physicians that practice in rural and frontier areas tend to play
an even larger role in mental health care provision than their urban
counterparts. This is in part due to the relative scarcity of mental
health and other health care professionals in these outlying areas of
the country. Other factors include the apparent preference rural
residents have for primary care physicians (Johnson, 1995) and the
stigma often associated with seeing a mental health professional.
Unfortunately, sparsely populated areas without established mental
health services (i.e., counseling) or providers (i.e., psychologists,
social workers) also tend to have relatively few primary care
physicians to act as substitutes. Nonmetro and frontier areas possess
far less physician coverage than more urbanized areas even after
controlling for population size. For example, Frenzen (1991) found
that in 1988, the ratio of primary care physicians per 100,000
persons for remote rural areas was 38.2; for the more inclusive
nonmetro areas it was 51.3. In comparison, metro areas had a ratio of
95.9.
Unfortunately, much has also been written about the deficiencies
of primary care physicians in their treatment patterns (Anderson
& Harthorn, 1989; Rost, Humphrey, & Kelleher 1994; Rost,
Williams, Wherry, & Smith, 1995), referral patterns (Anderson
& Harthorn, 1989; Farmer & Griffiths, 1992; Ozbayrak &
Coskun, 1993), and training to treat people with mental disorders
(U.S. Congress, 1990; Zimmerman & Wienckowski, 1991; NRHA, 1992).
However, there is a growing realization that, regardless of
shortcomings, primary care providers will continue to be sought out
by patients for care of mental disorders, due to preference or lack
of alternatives. Thus, a more recent focus has been on improving the
link between primary care providers and mental health specialists.
This may include integrated clinics, telecommunication links, or
simply improving the competency of primary care providers through
clinical practice guidelines, utilization of screening instruments,
or greater contact with mental health professionals.
Conspicuously absent from most of these studies, commissioned
reports, and policy papers, is the voice of the rural primary care
provider. Perhaps due to their intense practice schedules, little has
been written from their perspective. Accordingly, this paper presents
the findings from a focus group held in early 1998, of a group of
rural primary care providers who practice on the Western plains.
While it would be far too presumptuous to suggest that this group of
rural providers represent the thousands of physician, nurse
practitioners, and physician assistants who treat rural and frontier
residents every day, it does provide some insight into their
perspective.
Methodology
As part of the Frontier Mental Health Services Resource Network,
focus groups of providers and consumers were held in many rural
locations throughout 1997 and 1998. The were held to better
understand how people receive mental health services in the most
remote areas of the country. This particular focus group was held
during the winter of 1998 and consisted of six providers: three
physicians, two nurse practitioners, and one physician assistant. All
the providers practice in rural communities within a 30-40 mile range
from each other.
All can be characterized as generalist providers who actively see
and manage patients, many with serious mental disorders. Most of
their patients have few or no other local choices, except for a visit
from a mental health outreach worker from the nearest urban area
(population 65,000, approximately 50 miles away). Three of the group
members were male and three were female. The only unusual feature of
this group of providers was their age. With the oldest group member
being 49 years of age and the youngest being less than one year out
of his internal medicine residency program, these providers are
clearly younger than your average rural provider. On the other hand,
these group members may represent "the new rural provider". Again, no
claim is being made that this group represents anything beyond the
views of the six members themselves.
The group was convened at a central location away from their
clinics to discuss the extent to which mental health services are a
part of their practice. The participants discussed their treatment
and referral patterns, their training and competencies, and their
relationship with the formal mental health system. The entire focus
group discussion was audio taped, with the permission of the group
members, and subsequently transcribed. Below I have attempted to
juxtapose the contemporary literature on the role of primary care
providers with the comments from focus group members. As one will
see, in some areas the comments of the focus group members mirror
previous findings in the literature. However, in other areas, new
data emerged.
A note about confidentiality; all members of the focus group were
assured that their identities would be kept strictly confidential. As
this group of providers would be easily identified if their practice
locations were revealed, the fictitious town of "Plainville" was
created to represent their practice location. Two additional
communities are referenced in their comments. The first is the
closest urban community, a college town of approximately 65,000,
which I have named Collegeville. The second is the largest
metropolitan city in the state (population over 1 million), where
large tertiary centers are located. I refer to this city as
"Metropolis".
The Role of Primary Care Providers
As mentioned above, it is clear from previous literature that
primary care physicians provide a large percentage of the mental
health services to patients with mental disorders. This was clearly
true among our focus group participants. All viewed mental health as
a significant part of their practice. When asked to estimate what
percentage of their patient load is primarily mental health, most
estimated 10 percent. When further asked what types of common
disorders their patients' experience, the most common disorders were
depression, anxiety/panic attacks, attention deficit disorder, and
dementia among the elderly.
It is also important to recognize that, since these providers are
virtually the only ones in Plainville, their patient load comes from
a variety of sources. These providers not only have their private
clinic and hospital practice, but they must provide care at nearby
nursing homes and at the county jail. This diversity leads to
providers always feeling inadequate with some of their patients. As
one physician noted, "I have a pretty clear idea of how far I can
go with a depressed patient ... but the place where I really get
stuck all the time is with geriatrics. Particularly dementia, they're
real tricky and they mask a lot of things. ...they tell you what you
want to hear. They want to please you and then you find out from
their family that, oh yeah, they're running around in their underwear
out at 6:00 in the morning. You know, yeah, that kind of thing."
Another provider noted, "...what's been interesting since
we've been covering the jail, that's another whole segment there,
that population has a lot of significant mental health problems.
...they all fall between the cracks....they've been on medication,
they come in, and it's been stopped. Then it's really a difficult
thing ... you know, being confined and not having their medication,
not having someone to send them to or try to find out what they were
on. It really is an area that needs to be dealt with somehow."
As suggested, these providers take their role as mental health
providers seriously. Unfortunately, they have few local specialized
services to access for their patients and describe what can be best
called a fragmented system. When asked to describe the mental health
resources, one provider noted that, "maybe one psychiatrist comes
out periodically." Another provider quickly noted that the
psychiatrist covers three counties. Further discussions about another
area psychiatrist quickly displayed the fragmentation. When asked if
this second psychiatrist came from Collegeville, he noted, "I'm
not sure where he comes from. I guess that's the whole idea is that
we do not know!" Another focus group participant noted, "And
another particular entity that I think we're missing are care
planners, or what's that term, 'care coordinators'. We are
desperately in need of those folks to just let everyone know what's
going on with this patient."
When asked how they cope with such fragmentation, these providers
displayed the same resourceful ingenuity found in all sectors of
rural life. "But Plainville is a small enough town," one
participant noted, "so we regularly ... discuss patients who are
really difficult who - most of whom turn out to be people with a
mental health diagnosis or substance abuse diagnosis. But what we
have really done is we've developed kind of a, not just
practice-wide, but community-wide approach to them, so that when my
patient X shows up in the ER, everybody kind of knows what to tell
her. And that's one of the advantages of this real small system."
General Competencies
A number of articles have concluded that non-psychiatrist or
primary care physicians are, by and large, inadequately prepared to
recognize, refer, or treat mental disorders (Feldman, 1978; Pincus,
Strain, Houpt & Gise, 1983; Jones, Badger, Ficken, Leeper &
Anderson, 1988; Zimmerman & Wienckowski, 1991; Barrett, 1991;
NRHA, 1992). Other possible reasons for this drawback, besides
inadequate training in psychiatry/psychology, include:
- heavy patient load and time constraints on patient visits
- expectations of authority and peers
- medical school selection processes
- students' experiences in medical school.
- patients' lack of complaints concerning mental disorder
- lack of familiarity with the patient
- uneasiness about confronting the patient with the
diagnosis
- apprehension about submitting the patient to possible
side-effects of drug treatment
- mistaking symptoms of mental disturbance for situational
adjustment reaction
- a lack of interest in psychiatry (Feldman, 1978; Orleans,
George, Houpt, & Brodie, 1985; Fogel, 1993; Zung, Magill,
Moore & George, 1983; National Institute of Mental Health,
1986; Kelleher, Holmes & Williams, 1994)
Somewhat contrary to previous findings, Andersen and Harthorn
(1989) found that primary care physicians recognized the presence of
mental disorder essentially as well as mental health professionals
(e.g., psychiatrists, psychologists). However, these physicians were
less accurate in their diagnoses of affective, anxiety, somatic, and
personality disorders. Generalist physicians were most accurate (81%)
in recognizing organic disorders and least accurate (14%) in
identifying personality disorders. Only about one-half of the
physicians correctly identified anxiety (49%), somatic (49%), and
affective (47%) disorders (Andersen & Harthorn, 1989).
There was significant consensus among the focus group participants
that they do the best they can, but clearly were not adequately
trained to provide a full range of mental health services. As one
physician succinctly put it, "And I think that, just speaking
freely, I don't think I'm adequately trained to do a lot of what I
do. So I make a lot of phone calls to psychiatrists I know in
Metropolis, and just ask- what would you do given the situation? ...
Well, I just don't feel adequate doing a lot of what I do. A lot of
hand holding." While another participant philosophically noted,
"Well, I think - I've used this line many times, I hope I haven't
seen more than I have. Because you don't know how much you miss. You
always know that there is more out there that you don't know, and
you're not recognizing. You just say, I'll take care of what I can
identify. And that's why the relationship with the patient is so
important."
Consequently, all the participants noted the need for better
training in medical school and residency programs. As one of the
older physicians noted, "I had to learn how to put in a chest
tube, and that's true, you do have to know how to put in a chest
tube. But how many times a year do you put in a chest tube when you
are practicing in a small town? Once, maybe. How many people are you
going to see with depression?"
At the same time, all the providers noted that while identifying
depression, or other mental illness is sometimes illusive, there are
more times when patients reveal mental health problems within the
course of a routine office visit. As one of the nurse practitioners
noted, "But you never know what you are going to get. They tell
the front office that they only have this. Then they get in and they
tell you they only have this. And then [at the end of the
visit] your hand reaches for the door handle and they say, 'I've
been using drugs for this period of time, and I'm thinking of killing
myself.' And then you go, oh." While another physician noted,
"...it's like they have been wanting to talk to you so they come
in under the guise of insomnia or whatever, and then the mental
health stuff starts surfacing."
It's reasonably clear that all of the participants were aware of
their apparent deficits in recognizing mental disorders among their
patients. At the same time they are quite honest and straightforward
about it. As one physician mentioned, "...I think that sort of
uncertainty is just one of the things you live with being a
generalist."
The Relationship between Rural Physicians
and Mental Health Professionals
When one reads the literature, one gets a clear impression that
there is a strain between these two professional communities. Much of
the literature is written by mental health professionals (primarily
psychiatrists and psychologists) and suggests that generalist
physicians do a poor job of recognizing mental illness in their
patients, over-prescribe medication, under-dose, and do not refer
patients frequently enough to mental health professionals.
This professional strain was quite apparent amongst the focus
group participants. Interestingly however, these participants told a
much different story than the literature suggests. For example, when
first asked about the percentage of patients they refer to mental
health professionals, instead of the relatively low percentages
(10-30%) cited in the literature (Shapiro & Fink, 1963; Locke,
Krantz, & Kramer, 1966; Fink, Goldensohn, Shapiro, & Daily,
1967; Orleans, George, Houpt, & Brodie, 1985), these providers
responded with figures that ranged from 40 percent to 80 percent.
Confused over this disparity, we discussed the definition of a
referral.
Through this discussion several things became clear. All the
providers in the group recognized the need for adjunctive therapy
(primarily counseling) in addition to the medical management of their
patients' medications. They were also acutely aware of the time
constraints that exist in a primary care medical practice. Thus, they
routinely seek out mental health counselors for their patients, which
they define as a "referral". These counselors may be masters prepared
counselors, or social workers, but rarely psychiatrists or
psychologists. These rural providers speak highly of these counselors
and rely on them to assist in the management of their patients with
mental illness. However, when asked about referring their patient to
a psychiatrist, they admit that this percentage is very small.
When asked what criteria they use to decide when it is time to
refer their patient's care to a psychiatrist, each provider had his
or her own criteria. However, some of the more common criteria
included: if the patient is acute (i.e., needing to be hospitalized);
if they come into the emergency room with a mental disorder; if,
after several attempts, their medication regimen fails; or if they
routinely find that they cannot meet a patient's needs within the
time constraints of a medical practice.
Another important factor influencing referral patterns was the
expectation of the rural patient. Many of these physicians believe
that their patients fully expect them to meet all their health needs
regardless of origin. Consequently, some of these rural providers
feel pressure to treat patients, even through all their uncertainty,
due to this patient expectation. As one provider stated, referring to
other rural physicians, "... these good old boys were there to
deliver the babies, to fix the hernia, to take out the appendix, and
they pulled them through all of these things. And now mental health
is another thing he can fix because he fixed all these other things."
Overall, it is fair to say that referral to a psychiatrist is
closer to a last resort that a first resort. Most of the focus group
participants noted that because of past experiences they are
uncomfortable referring any but the most acute patients to
psychiatrists. One noted that by not referring patients she was
"protecting them from the [mental health] system." Others
recognized that this aversion to referring patients to psychiatrists
further strains the relationship. As one physician noted, "And I
think that creates a bad rapport between the folks (psychiatrists)
that we do use because we send them our 'bombs'. And they think,
'here's someone else from Plainville!"
Another problem voiced by the group was the lack of communication
between rural primary care providers and urban psychiatrists. This is
often reflected in the amount of patient information received by the
rural provider from the psychiatrist after a referred patient returns
to the rural community. These providers feel that, unlike other
medical specialists (e.g., cardiologists or oncologists) who provide
feedback to the primary care provider regarding the diagnosis and
treatment regimen of their patient, psychiatrists use the veil of
confidentiality to keep information from them. This creates a great
deal of frustration for the primary care provider who must now deal
with the patient using incomplete information in their ongoing
treatment after their return. In fact, as one provider related to the
group his frustration about not getting even a discharge summary from
a psychiatrist after one of his patient's inpatient episodes, none of
the other providers seemed even remotely surprised. As one physician
reflected, "... the mental health profession is now so scared of
sharing information, much more than in any realm of medicine. So like
this day-of-discharge summary thing you were talking about, they had
to do a whole extra song and dance about sending any information back
to you about the patient who you referred in with an acute problem.
Because they are so worried about confidentiality, although you are
the referring physician. ...But they're in a kind of legalistic mode
rather than a serve-the-patient mode."
Further, some rural providers appear to be quite skeptical of the
quality of service psychiatrists provide. One physician noted,
"... but anymore, the psychiatrist is someone who calls himself
or herself a psychopharmacologist, and they spend 15 minutes with a
patient anyway and have a less clear idea than I do about what's
going on and spend their time adjusting their medication, and that's
all they do. ... and so the services are just really stinky."
However, the greatest display of animosity toward psychiatrists
came from the most senior member of the focus group. A physician who
has practiced in both urban and rural environments and has also
taught in one of the state's residency program, he boldly stated,
" I think psychiatrists are really; I hate to over-psychologize
about psychiatrists, but I think they are at this time, they're a
miserable bunch! You know, they feel their avenue, their professional
venue being shrunk (you should excuse the expression). But what can
they do, what can they make, what their view is, and I think they are
just pretty miserable people. And that makes them hard to deal with
as colleagues too. Because it is very hard to get them to do what you
want, or what the patient needs, or to see you as a customer. Because
it's like any other, it's like your unhappy waiter that throws food
at you. That's how I feel. I practiced in Collegeville for nine years
and I knew everybody. And I still know all the shrinks in
Collegeville, but when you ask me who did I like to refer to there,
it's still zero. I use them some, but there's nobody I really
like."
While this remark was the boldest of all, none of the other focus
group participants came to the defense of the psychiatric community.
Clearly there is a significant gulf between these provider groups
that needs to be addressed.
Summation and Limitations
As noted earlier, no attempt has been made to suggest that this
group of rural providers is representative of any larger group or
constituency. However, their attitudes and opinions can provide us
with some insight into the perspective of the rural primary care
provider. With that said, I have attempted to juxtapose salient
findings in the literature regarding this "de facto" mental health
system with the knowledge, attitudes, and opinions of this small
group of providers.
In general, one could conclude that many of the findings in the
literature have been confirmed. Generalist providers do seem to
provide a large percentage of the mental health services in rural
areas. Additionally, while, as the literature suggests and the focus
group confirms, these providers do the best they can, they often feel
uncertain and less than fully prepared to serve the mental health
needs of their patients. Yet as one provider noted, uncertainty is a
phenomenon all too familiar to the generalist provider.
What was surprising was the extent to which these providers
recognize this deficit and seek out "mid-level" mental health workers
to provide adjunctive therapy for their patients experiencing mental
illness. Focus group participants noted that somewhere between 40-80%
of their patients with mental disorders are referred to these mental
health workers. This number far exceeds the literature that suggests
as few as 10-30% of eligible patients are ever referred to a mental
health professional.
Of course, the difference appears to be in the definition of a
referral. The literature usually defines referral as a change in the
provider who supervises the medical and psychological management of
the patient experiencing a mental disorder. These providers defined a
referral as the act of seeking adjunctive counseling in addition to
their medical and supervisory management of the patient. If this
differential definition is common, then it may be quite fallacious to
assume that primary care providers who choose to manage patients with
mental disorders are inadequately providing or ignoring the
counseling needs of these patients.
Another problem highlighted by the focus group was rural providers
apparent inability to get patient information back from the urban
psychiatrist after they refer patients to them. The frustrations
expressed by these rural providers appear to be a function of two
differing standards of patient confidentiality. Where in other
sectors of medicine the routine sharing of patient information
between the primary care provider and medical specialist is the norm,
psychiatrists appear to use a different standard. Consequently, rural
providers often have to treat patients returning home from
psychiatric treatment with incomplete information on what occurred
during hospital stays and without other vital information. This not
only frustrates primary care providers, but it further compounds the
referral problem by decreasing the probability that the rural
provider would ever refer future patients, except for the most acute.
One would think that a reasonable compromise could be achieved to
ensure that patient confidentiality is upheld and necessary
information is shared amongst all appropriate providers.
Finally, it was surprising to find the extent to which these rural
providers felt animosity toward the psychiatric community. Throughout
the focus group, few if any kind words were spoken about
psychiatrists. These rural providers were wary of the way they have
been treated by the psychiatrists they refer to and were equally
concerned about the quality of care their patients receive. This
feeling is apparently so common among these providers that their
tendency is to try everything they can to avoid referring the
patient. As one provider noted, "...to protect them from the
[mental health] system." It is unclear whether it is
fully realized at this time how great the gulf is between these
professional communities. However, until this gulf is truly
recognized, it is hard to imagine how one might initiate a process
that will begin to close it.
Lastly, it is important to note again that the data for this paper
comes from a very small sample of rural providers in one location.
Therefore, it would be extremely risky to suggest that these views
are truly representative of all rural providers. However, they do
provide some interesting insights and raise some long standing
issues. Further, there is little doubt that the voice of the rural
primary care provider in this discussion is long overdue.
Consequently, further data collection from other primary care
providers in other rural locations is sorely needed to help us better
understand the dynamic relationship between these two important
provider groups.
References
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recognition, diagnosis, and treatment of mental disorders by primary
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Barrett J. (1991). Treatment practices in primary
care: Setting directions for health outcome research. Journal of
Family Practice, 33, 19-21.
Farmer, A., & Griffiths, H. (1992). Labeling
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717-723.
Feldman, A. (1978). The family practitioner as
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Fink, R., Goldensohn, S.S., Shapiro S., &
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10
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James A. Ciarlo, Ph.D., Project Director
This project is supported by the
Center for Mental Health Services, Substance Abuse and
Mental Health Services Administration
Contract No. 280-94-0014
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