A great benefit of living in today's "inter-connected" information rich society is our increasing ability to see the relationship between one field of study and another. Such a phenomenon has never been more apparent than the way we view the mind and body, especially in medicine and also in the social sciences and education.
In fact, it can now be said with a fair degree of certainty that illness or disease or injury when seen in the office of a pediatrician or primary care physician almost always has both a physical and mental part to it. Consider the child who presents with an upset stomach and irritability. Could it be that some chronic or current anxiety is part of the cause? What about the increasingly obese adolescent? What behavior changes are necessary to address this very important public and personal health issue?
Why, then, do we continue to deal with physical and behavioral health separately? Why do private and public insurers avoid dealing with an overwhelming body of evidence by failing to motivate the integrated practice of medicine? Why do schools of medicine and the allied health sciences give priority to treating physical or somatic patient issues while seeming to subordinate behavioral health and psychological change? The answer to all of these questions seems to start with "system inertia" and end with "a need to change by so many parts of the system" that no one part seems to have the energy to make the changes needed.
With what we now know about pediatrics and health care science, it seems foolish to continue on our current path, treating children as parts rather than a whole person living within the context of family and community. There is good reason to believe that when doctors and allied health practitioners begin to collaborate and treat children (and others) in an integrated fashion, that the cost of health care begins to decline, over time, with diminished use of expensive places of treatment (e.g. emergency rooms) and diminished frequency of visits for care.
What are we waiting for? For one thing, change does not happen overnight. First, we need general concurrence that change needs to occur; two Surgeons General, Dr. Satcher and Dr. Carmona, have indicated clearly that this is, indeed, the way to go. Next, we need to realize that getting primary care and behavioral health disciplines really to start working with one another requires agreements on the protocols of care and a means to safeguard patient information. That is not an easy task and a system of best practices will need to evolve over time.
Insurers will need to start reimbursing integrated practices for the time required to share information and assess what elements of care are necessary to treat the entire patient. Regulators at the state and federal levels will need to assess what laws and regulations may have to be changed to stop perpetuating segregated medicine, unless absolutely necessary. Finally, schools of medicine and allied health disciplines will need to review their curricula to determine whether structural changes are necessary in the way healthcare is conceptualized and taught, evidence for which is beginning to emerge across the country.
These new integrative health care systems must have "interlocutory" disciplines that foster effective recovery and reintegration into the context of family life and healthy peer relationships, specifically including active school and community participation.
The message for the way we practice medicine and the way we view health is clear - segregated care is inefficient, perpetuates stigma, reduces access to needed interventions and promotes escalating health care costs. Can we fix our segregated health care system? Can we put it all together again? I think we must.
Donald P. Galamaga is a member of the Board of Bradley Hospital, Rhode Island, and the former RI State Mental Health Director.
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