Time was when the family doctor knew each patient, each family, their idiosyncracies, pressures, distress and pressure points. That was in the days when medicine was considerably less complex and doctors worked 70-80 hours per week. Office visits were not limited to 10-15 minutes and there was no such thing as “only two things per visit; if you have other issues to discuss with the doctor, you will need to book another appointment”.
That was also in the days when housecalls were common which served to render urgent in-home care but gave the doctor some insight into living conditions and family dynamics. The thousands of drugs that have an impact on the body and the moods just were not available so treatment of known mental challenges was pretty limited.
Psychiatric hospitals existed in every province and state in which those who could not be looked after by the family unit were sent there, often for the rest of their life.
That is what family medicine was all about “back in the day!” So much has changed. Drugs for every mood, drugs to help manage bi-polar disorder, drugs for ADHD, Schizophrenia, Depression, Anxiety, and the list is seemingly endless.
Every drug has some side-effects or “unintended consequences” and in the classic “Pills That Don’t Work” by Dr. Sidney M. Wolfe in 1981, of the 610 drugs reviewed all lacked evidence of effectiveness.
Fast forward to 2020 and, depending on your source, Mental Health is in Crisis in most provinces if not all. The rapid growth, if not epidemic, of ADHD, Bi-Polar disease, Depression, Asbergers, and Suicide have created a societal situation that must be viewed as in crisis. Add to that the rampant increase in substance abuse, homelessness, and now the recognition that addictions include gaming and we have a mess on our hands.
The family doctor, spending just a few minutes once a year or so with patients, cannot possibly be in touch with the impact that any one of these issues may be having on persons in his/her caseload. Not that they would not wish to, but mental issues are so often difficult to recognize and require significant time for assessment. Further, the 40-70,000 persons who have no access to a family physician have even less chance of having their mental distress picked up and recognized.
Another phenomenon of the change in family medicine is the large number of stories of people trying to get testing and diagnosis of a mental issue of aging. One very bright lady described how her mother, following three years of pleading, had to have a melt-down in the family doctor’s office in order to get her husband to a Geriatrician for what turned out to be diagnosis of Dementia. It was an agonizing three years for the family.
Another was the case of a senior living with Depression on top of several other medical issues, falling regularly at home, but being treated by a variety of physicians, each prescribing and changing the 17 medications that, as it turned out, were making him very unsteady and causing frequent crises. For whatever reason, all the doctors prescribing medications did not, in the normal course of events, have occasion for collaboration. On consult by a Geriatrician, the drugs were significantly reduced and changed resulting in improved lifestyle.
The point is that certain cohorts of the population, in order to prevent crises in their lives, need to have their cases managed by a team and a Case Manager; this person is in possession of all health records of the patient and has sufficient time and advanced training to help the person stay out of crisis. This is not a replacement of the family doctor but an adjunct to the role of the family doctor. For the 32% of persons in this province who are potential mental health clients and the frail seniors whose chronic conditions and therapies need to be carefully and continuously managed, a trip to the family doctor’s office for 15 minutes once a year is woefully inadequate. The skilled, well trained family doctor cannot devote that much time to managing specific patients.
This is not a criticism of our terrific family physicians; New Brunswick has some jewels. But it is a recognition of the fact that the current approaches to dealing with those with mental illness of whatever type just is not working and a simple referral to a mental health clinic or a psychiatrist is insufficient. This is not the fault of any one person or any one group.
It is a commentary on the state of leadership in the field, however. Of all the areas of specialty in health care, Geriatrics and Mental Health have not exactly carried with them either the glamor or the high earning potential found in other fields. It really takes a person with unique motivation to want to work the rest of their career with kids, adults, or seniors experiencing mental illness. It is much more interesting, exciting, and rewarding to repair malfunctioning eyes, bones, bodily systems, hearts and more. But the prospect of spending every day listening to sad stories, trying to assess root causes, then to figure out proper therapies that will seriously help the patient is appealing only to a select few.
It is much easier and more professionally rewarding to engage in practice in which results can be seen day to day, week to week. Enabling people to walk again without pain or to see without the haze of the cloudy lens gives almost instant satisfaction.
Mental health services can be an exciting and rewarding professional activity whether you are functioning in the capacity as a social worker, a psychometrist and analyst, a psychiatrist researching therapeutic effectiveness of drugs and interventions, or a psychiatric nurse ensuring that the patient stays on the meds and does not come to harm.
But not without leadership. John Maxwell, one of leading communicators on Leadership, often makes this point: Everything either rises or falls on leadership! Organizations grow and thrive with great leadership; they also fall with leadership gone off kilter! If we have a crisis in Mental Health Services, which many informed people in New Brunswick believe to be the case, we then return to the question: Where is the leadership?
Critics and those with political agendae would say it is all “underfunding”! But they say that about everything; it is the one simple excuse for all mediocrity in our system. But why is it that some health care organizations perform with stellar results while others struggle even while receiving comparable funding levels? It is not more funding but visionary leadership.
So how do we apply that principle to mental health services? If there is a concensus that the current services are leaving lots of people behind, then the answer is not, surely, to keep pouring more money into something not achieving desired results but to put all the cards on the table, do a proper evidence-based assessment, figure out what is working and what is not, engage some really fresh thinking in the process, and chart a brave new path forward. Will this work? Will it resolve the issues in Mental Health Services? Not without truly inspired, empowered leadership.
Ken McGeorge,BS,DHA,CHE is a retired CEO in major teaching hospitals and long-term-care facilities. He was co-chair of the New Brunswick Council on Aging and is a columnist with Brunswick News. His email address is email@example.com.
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Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.