Hope for Improved Mental Health Care

Medical educators lead the charge, but more work remains.

A similar version of this post was published earlier today in Psychology Today.

In my previous posts on medicine’s loss of mind, Descartes, and modern science, I described the medical profession’s profound dereliction of duty for its most common patient population. Medicine completely fails to train primary care physicians in basic mental health care even though they provide 85% of it; psychiatrists provide no more than 15%. And you already know that evidence of poor mental health care resounds. Indeed, I’ve never heard anyone dispute the assertion that mental health care is vastly inferior to physical disease care. And it’s a refractory problem, documented since the beginning of the Healthy People initiatives in 1979.

Giuseppe Bartolomeo Chiari  (1654–1727): Allegory of Hope

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Nevertheless, while there’s no guarantee, I’m going to offer some room for cautious hope. And from a surprising source when you recall how delinquent medical education has been. The light at the end of this long tunnel comes from medical educators.

Medicine’s teachers have, indeed, come to the forefront is espousing the incorporation of patients’ psychological and social features, of course integrating them with physical disease problems. This is especially propitious because educators train medical students and residents—our future clinicians—and instill in them the basic values and skills required to care for patients. This ferment has been brewing since 1977, so it’s no pie-in-the-sky. By integrating psychosocial and disease features, medicine not only becomes more scientific but also more humanistic—humanism and science linked.

Let’s review how medical educators overrode the most hallowed precept of their profession—the love affair with physical diseases.

You heard about the biopsychosocial (BPS) model and the patient-centered interview (PCI) in my modern science post.1 George Engel articulated the BPS model in 1977 as a more scientific, systems-based approach where medicine complements its disease interest by including patients’ more human psychological and social dimensions.1 The PCI was introduced by Levenstein, McWhinney, and others in 1980 to show how to obtain BPS information about the patient and to form a strong doctor-patient relationship.1 This BPS/PCI orientation, by definition, encompasses mental disorders and highlights them as medicine’s responsibility.

Under the aegis of the Association of American Medical Colleges (AAMC), who guide what medical schools teach, medical education quickly embraced the BPS/PCI advances. Virtually all medical schools and residencies now endorse the BPS model. Indeed, it’s found in most mission statements and other guiding principles.2 In a truly dramatic change over a relatively short time, since 1977, the BPS model is supplanting the disease-only model that has guided medicine and medical education since the late-1800s in the U.S., the early-1800s in Europe.3

In parallel, as the means for operationalizing the BPS model, nearly all medical schools now train their students in the PCI. Patient-centered training includes not just communication and the physician-patient relationship skills but also skills for educating patients and counseling them in respectful ways, for example, negotiating treatment plans rather than telling patients what to do.4 As well, many schools now include training in medical ethics and social medicine.

The BPS/PCI approach contrasts to my and other older physicians’ experiences. We received no instruction in interviewing or the physician-patient relationship. Nor did we have training in the personal awareness, self-care, ethics, or the moral aspects of medicine that have become commonplace in current medical education.

A crowning achievement of the BPS/PCI approach, the AAMC recently added the requirement for knowledge of psychosocial material to its Medical College Admission Test for undergraduate students applying to medical school.5 The AAMC intends to identify, before they get into medical school, the students who will have a more balanced and humane perspective, a major departure from earlier admission policies that selected students with interests and skills restricted to the sciences. When I took these qualifying entrance exams many years ago, there were no questions on psychology or the social sciences. Therefore, my fellow premedical students and I focused exclusively on the basic sciences—inorganic chemistry, organic chemistry, quantitative chemistry, biochemistry, physics, all levels of mathematics, zoology, embryology, comparative anatomy, physical anthropology, genetics, and the like. Little time remained for more broadly-based learning about man’s humanity, which comes from studying history, literature, theater, music, composition, psychology, and the all social sciences. The AAMC changed this.

We also find similar advances in post-graduate (residency) training. Residencies now incorporate the same BPS and PCI principles in the milestones and competencies they use to decide if residents are progressing satisfactorily and, eventually, should graduate.6 Respectful interactions, professionalism, and communication and doctor-patient relationship skills are becoming part of all residency training and evaluation.

In sum, there is little question that modern medical educators embrace a BPS/PCI approach, one that has made medicine more scientific and humanistic by integrating the personal elements with patients’ disease features.

Alan O’Rourke: Comic which shows the difference between wanting change and wanting change.

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Here’s the conundrum. Medicine’s advances do not include mental health instruction. Not even a modicum of progress has materialized. Students and residents continue to receive no more than 2-3% of their teaching devoted to supervised mental health training. The inevitable question arises. If medicine now integrates psychosocial features, why does it not train its graduates in mental health care? That should follow logically and medicine is a profession that prides itself in being logical.

In my next post, I’ll analyze this non sequitur, indeed one so strange we must entertain that an unrecognized problem exists. Maybe medicine’s resistance to mental health is not the main problem, maybe we must look elsewhere to resolve the mental health crisis.

We’re breaching ground zero in the mental health crisis.

Robert C. Smith, Copyright 2020

REFERENCES

1. Smith R, Fortin AH, VI, Dwamena F, Frankel R. An Evidence-based Patient-Centered Method Makes the Biopsychosocial Model Scientific. Patient Educ Couns 2013;90:265-70.

2. Association of American Medical Colleges. Basic Science, Foundational Knowledge, and Pre-Clerkship Content — Average Number of Hours for Instruction/Assessment of Curriculum Subjects. Association of American Medical Colleges; 2012.

3. Porter R. Medical Science. In: Porter R, ed. Cambridge History of Medicine. Cambridge: Cambridge University Press; 2011:136-75.

4. Fortin VI AH, Dwamena F, Frankel R, Lepisto B, Smith R. Smith’s Patient-Centered Interviewing — An Evidence-Based Method. 4th ed. New York: McGraw-Hill, Lange Series; 2019.

5. Kirch DG, Mitchell K, Ast C. The new 2015 MCAT: testing competencies. JAMA : the journal of the American Medical Association 2013;310:2243-4.

6. Association of American Medical Colleges. Core Entrustable Professional Activities for Entering Residency — Curriculum Developers’ Guide. Washington, DC: Association of American Medical Colleges (AAMC); 2014.

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