“When I went to school to be an accountant, I never thought I’d wind up being a community advocate for people who have no access to care,” says Paule Anne Lewis, President and CEO for San José Clinic. She asks “Expanding the Bounds of Care Delivery” panelists what set them on the path to their work today in expanding patient access to mental health, addiction, and pain treatment.
“I’ve always liked the brain, the mind . . . how it makes us behave both in health and in illness,” says Jürgen Unützer, Chair of Psychiatry and Behavioral Sciences at the University of Washington. He also enjoys helping people. But, he says, “I didn’t fully appreciate at the time I was in medical school that there was a thing called the denominator.”
Clinicians are good at the numerator: helping the people in their waiting room. But the denominator, which Unützer discovered during training in public health, is all the people not in your waiting room — those who might have once been but aren’t coming back, or who should be there but aren’t. “When you put those two things together, you realize we have a huge gap between what we can do under the ideal circumstances and what we do do,” he says.
When Unützer moved to UW Medicine — the only medical school for a five-state region that covers 27% of the U.S. landmass — he noticed a lack of psychiatrists. And he realized the best way to address mental health issues in the area was to collaborate with other care providers.
“We have to think about, who can we partner with? Who all is out there seeing these patients, and how do we create partnerships? What can I as a mental health provider do to help all those primary care providers who are struggling with the patients in their offices?” These questions germinated the idea for a collaborative care model that integrates mental health into primary care.
Corey Waller, Senior Medical Director for Education and Policy at Camden Coalition of Healthcare Providers’ National Center for Complex Health and Social Needs, set out to be an emergency medicine physician. Six months into his first job, he realized he hated it.
Having trained at a level-1 trauma center in Philadelphia, where he grew used to treating stab and gunshot wounds, Waller moved to the Midwest. “I went out to middle America where they’re not stabbing and shooting each other, but they’re all really sad,” he says. “That’s what I saw, every day: debilitating sadness from patients.”
In trying to figure out why he hated his job, Waller realized it was the super-utilizer patients who repeatedly showed up to the ER. Over the next 6 months, he asked 30 of these patients to come into the ER on Wednesdays so that he could help them determine what was truly going on underneath that back pain, that headache, or whatever physical ailment they had. One hundred percent of the 30 patients said yes, and 100% showed up. Getting to know them, Waller learned that the roots of their issues were things he didn’t understand — addiction, chronic pain, mental health complaints, poverty, and suffering — things that were just not being taken care of.
Waller decided to train in addiction. But patients don’t come to the ER complaining of addiction — they talk about pain, and they want an opioid to feel better. So Waller next received training in interventional pain and noninterventional medical management, and he convinced his hospital to build a clinic “dedicated to those patients who drove me out of emergency medicine.” For the next 5 years, he saw only super-utilizer patients who had been to the ER 10 or more times per year.
“It was amazing,” he says, “the ability to flip a switch on someone just using basic evidence-based approaches to medicine, and empathy, and how you could turn around somebody who you thought was an impossible person and actually make them smile and happy and productive.”
For Unützer, people like Waller are one of the most exciting things to happen in medicine over the past 10 years. “When [Waller] goes through this experience and we start talking to each other and with each other, together we’re a lot smarter and a lot better than if any one of us just did our thing,” he says.
“I’ve become a huge believer in there are none of us who are as smart as all of us. When the two of us find each other and we start thinking about what is it we could do together to help a patient, we can make an enormous difference.”
From the NEJM Catalyst event Expanding the Bounds of Care Delivery: Integrating Mental, Social, and Physical Health, held at Vanderbilt University Medical Center, January 25, 2018.