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Child and adolescent psychiatrys role in a professional dilemma

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Title: Child and adolescent psychiatrys role in a professional dilemma


1
Child and adolescent psychiatrys role in a
professional dilemma
Bela Sood, M.D. Virginia Commonwealth
University Douglas Robbins, M.D. Maine Medical
Center Co-Chairs, Clinical Practice Committee,
SPCAP
2
MCOs/ Litigation other Monsters Setting
Expectations for Professional Ethical Clinical
Practice
3
  • The practice of modern medicine..disparities,
    dependence on market forces to transform health
    care systems, tempts physicians to forsake their
    traditional commitment to the primacy of patient
    interests
  • To maintain the fidelity of our contract with
    society have to reaffirm our dedication to the
    principles of professionalism for not just our
    individual patient but to the health care system
    as a whole and thus improve health care for
    society overall..

4
  • Medicines contract with society
  • pt interests above those of the physician market
    forces must not impede this
  • Pts autonomy empower to make the right decision
    with shared knowledge, honesty about medical
    errors
  • Principles of social justice fair distribution
    of health care resources, (reducing
    discrimination)
  • Commitment to improving quality of care,
    improving access to care

5
  • Commitment to setting competence and integrity
    standards (life long learning), expert advice on
    maters of health
  • Commitment to the integrity of scientific
    knowledge that is based on evidence/experience
  • Commitment to honor the relationship by not
    exploiting the dependent vulnerable position for
    the patient for financial, sexual or other
    personal reasons
  • Commitment for managing conflict of interest in
    order to be trusted
  • Self regulation, remediation and discipline of
    members who do not meet professional standards.

6
  • The ethics and professional standards of practice
    as we define it as a profession
  • The external elements that impact our ability to
    deliver care ethically and professionally

7
Clinical work.and Academia?
  • Financial viability?
  • Keeping up with the competition?
  • Outsourcing or developing niche
  • All things to everyone or boutique operation
  • Central to mission of the operation

8
Erosion of Life as we knew it
  • Time constraints
  • Man Power shortage
  • Reimbursement
  • Mismatch between expectations and delivery of
    goods

9
Role of Technology
  • (New) Knowledge used as a stick by consumers
    and gatekeepers
  • Challenges
  • How to..stay ahead
  • avoid defensiveness
  • set standards for trainees

10
Role of the child psychiatrist
  • Pill Pusher
  • Holistic Treator
  • Psychotherapist
  • Diagnostician
  • Or
  • All to some
  • Or some to all

11
The brave new world.
  • The emergence of managed care organizations
  • The evolution of MCOs
  • The role of physicians
  • The role of this middle man
  • To play or not to play is the question
  • Anti trust and health care laws

12
Managed Care Organizations
  • Challenges
  • How and when enough is enough?
  • How to impact practices of MCOs
  • How can our colleagues who serve as medical
    directors impact policy for MCOs?
  • Role of The Insurance Commissioner and SEC
  • Role of antitrust and health care law

13
Litigation
  • Not a high risk specialty
  • But
  • the specter of metabolic syndromes and black box
    warnings.drug drug interactions
  • The potential for violence
  • The appearance of inaction
  • The relationship problems with families/ other
    disciplines

14
Mitigation of Risk
  • A focus on understanding the risks and why they
    exist
  • Developing a rationale for why we do what we do
  • Helping trainees develop rational logical
    paradigms for clinical care, skills for clear
    articulation
  • Focus on relationships, listening with the third
    ear

15
  • Patient abandonment
  • Inappropriate behavior with pt/colleague.
    example
  • Inappropriate management of patient
  • How does termination occur firing and hiring
  • Do doctors tell on doctors or guild
    protection.. physician heal thyself

16
When in doubt is there help?
  • Supervision with colleague
  • Professionalism committees set expectations at
    school level rules/ behavior
  • Ethics in clinical practice university risk
    management/legal team
  • Ethics committee of AACAP

17
Standard for Trainee
  • Challenges
  • Working in a multidisciplinary team
  • Espousing a democratic decision making process
  • Maintaining authentic and safe medical management
  • Fine line before autocratic/respondent superior
    role emerges

18
  • Standards of Professional Behavior
  • These standards describe behaviors expected from
    faculty, housestaff, and students in the School
    of Medicine
  • Recognize their positions as role models for
    other members of the health care team.
  • Carry out academic, clinical and research
    responsibilities in a conscientious manner, make
    every effort to exceed expectations and make a
    commitment to life-long learning.
  • Treat patients, faculty, housestaff and students
    with humanism and sensitivity to diversity in
    characteristics such as culture, age, gender,
    disability, social and economic status, sexual
    orientation, etc. without discrimination, bias or
    harassment.
  • Maintain patient confidentiality.
  • Be respectful of the privacy of all members of
    the medical campus community and avoid promoting
    gossip and rumor.
  • Interact with all other members of the health
    care team in a helpful and supportive fashion
    without arrogance and with respect and
    recognition of the roles played by each
    individual.
  • Provide help or seek assistance for any member of
    the health care team who is recognized as
    impaired in his/her ability to perform his/her
    professional obligations.
  • Be mindful of the limits of one's knowledge and
    abilities and seek help from others whenever
    appropriate.
  • Abide by accepted ethical standards in the
    scholarship, research and standards of patient
    care.
  • Abide by the guidelines of the VCU Honor System.
  • These standards were proposed by the
    Professionalism Committee and adopted by the
    School of Medicine in September 2001. The
    standards are also available in print in the form
    of pocket cards and posters. Contact Debbie
    Stewart (804-828-6591, dstewart_at_vcu.edu) for
    copies.

19
Professionalism
  • Transparency
  • Honesty
  • Accountability
  • Unafraid to get the job done, yet not seen as
    on a power trip
  • Emotional intelligence to determine timing
  • The role of mezzanine people

20
Ethics
  • When to say no to patient care?
  • Evidence based practice vs. Instinct
  • The ideal and the real
  • Clear rationale 3.5 year old.

21
Audience input.
22
Challenges in implementing Evidence-Based
Practices
  • Child and Adolescent Psychiatrys role in this
    professional dilemma

23
Dilemmas
  • Child and adolescent psychosocial treatment often
    has limited effect. (E.g. Weisz JR, 2004)
  • The public health impact of what we do is
    insufficient.
  • Child Psychiatry has a significant array of EBPs,
    but they are rarely really implemented.
  • We are often reinforced for continuing previous
    patterns of practice.
  • Reimbursement patterns, Medicaid and insurance
    rules continue the status quo
  • The Feinstein Challenge We train residents in
    development and the art and science of treatment,
    and then their practices involve primarily
    medication management. Is this the role we
    intend for them?
  • SPCAP 2007

24
Barriers to implementing EBPs
  • 1. Limited applicability of the evidence to
    clinic populations
  • 2. Costs of implementation
  • 3. Clinicians discomfort with EBTs
  • 4. Lack of outcome assessment in clinical work
  • 5. Organizational culture

25
1. Limited applicability of the evidence to
clinical populations
  • Discrepancies between efficacy trials and
    effectiveness.
  • Heterogeneous clinical populations
  • Comorbid disorders
  • Social, economic, cultural diversity
  • (Hoagwood K, et.al., 2001)

26
Potential Solutions to the limited applicability
  • Common Elements or Modular approach. Menu of
    components. Matched to individual patient
    characteristics
  • (Chorpita BF et.al., 2007)
  • Evidence-Informed Practice vs. Evidence Based
    Practice
  • (Hamilton J, 2005)

27
2. Costs of implementation
  • Direct costs of training and supervision
  • Training time is not reimbursed
  • Some EBPs not reimbursed
  • Parent Management Training without patient
    present
  • In-home treatment
  • Collaboration with schools and primary care
  • Administrative time and costs
  • Costs of outcome assessment

28
Potential solutions - Cost
  • Outcome-based reimbursement
  • Risk of discouraging treatment of more difficult
    patients
  • Differential reimbursement for clinicians or
    programs using EBPs
  • E.g. adult ACT teams in New York treatment
    fidelity related to rate
  • Case rate reimbursement vs. fee-for-service

29
3. Psychiatrists and clincians discomfort with
EBPs
  • Limitations of time for training and supervision
  • Limitations on clinical contact time Managed
    care
  • Large number of EBPs too many to learn
  • Perceptions of rigidity or poor fit with patients
  • Comorbid disorders
  • Cultural and economic diversity

30
Discomfort with EBPs - continued
  • Top-down decisions to use EBPs
  • Perceptions that EBPs are not needed
  • Factors associated with openness to innovation.
  • Temperament
  • Support vs. anxiety, insecurity.
  • (Aarons GA, 2005)

31
4. Lack of outcome assessment in clinical
practice
  • The Bell Curve New Yorker, 12/6/2004
  • Feasibility Costs, burden to family
  • Absence of feedback loops for performance
    improvement
  • Potential mis-use of outcome data
  • e.g. negative reinforcement for treating
    difficult patients

32
5. Organizational culture
  • Macro-level Disincentives to innovation.
  • Medicaid and insurance rules and practices.
  • Behavioral expectations and reinforcers.
  • Productivity
  • Organizations sense of the public health
    mission, vs. survival
  • (Glisson C, 2007)

33
Theres hope Initiatives on implementation of
EBPs
  • Federal - NIMH, CMHS, SAMHSA, Other.
  • State initiatives
  • Colorado, Hawaii, California, Michigan, New York,
    Ohio
  • (Bruns EJ and Hoagwood KE, JAACAP, April,
    2008)
  • MacArthur Foundation
  • Annie E. Casey Foundation
  • Annenberg (Foundation
  • (Chambers DA et.al., 2005)

34
Tilting at Windmills?Advocacy for
Evidence-Informed Practices
  • Individual case reviews with payors
  • Refer to Practice Parameters and EBPs
  • Cost-effectiveness and benefits to clinical
    organizations
  • Evidence of effectiveness
  • Medical-Legal support
  • Role of the AACAP
  • The child adolescent psychiatrists role as
    leader of the multidisciplinary team

35
Training
  • Development of familiarity and comfort with
    outcome assessment as a routine clinical
    practice.
  • Role of the CAP as one who knows what really
    works whether or not we can do it now.
  • Maintain a focus on our responsibility to the
    community. Spokespersons for best practices.
  • Role as leader of the multidisciplinary team,
    aware of what is evidence-informed.
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