The Ideal Clinicians How Do We Find Him or Her Hint: Look at How They Were Trained

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The Ideal Clinician(s) How Do We Find Him or
Her? (Hint Look at How They Were Trained)

• Leighton Y. Huey, MD
• Birnbaum/Blum Professor and Chair
• Department of Psychiatry
• University of Connecticut School of Medicine

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The Continuum of Recovery
No Recovery
Partial Recovery
Fully Recovered
Resources and Support Required
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Old Description

• Well Trained
• What does this mean?
• Well trained in what?
• How is well trained assessed?
• .and by whom?
• Bio-Psycho-Social
• What does this mean?

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New Description

• Well-Trained Comprehensive Assessment,
  Treatment, and Follow-up
• Think in terms of multiple possibilities and
  narrow the choices as one gets to know the
  patient and the family
• Differential Diagnoses based on strong training
  in diagnostics
• Competent in Research Literacy
• The approach to individuals with a First Episode
  vs. the approach to individuals who have
  experienced multiple episodes is there a
  difference?

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• Well-Trained continued..
• Truly consider Biological, Psychological, Social
  Factors in the context of how the individual
  presents and what is ultimately desirable
  (cont)

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Comprehensive, Assessment, Treatment, and
Follow-up (continued)

• Biological
• Physical Health, Physical Symptoms
• Heredity
• Possible Contributing Factors to the
  Clinical Presentation
• Possible endogenous factors contributing to
  the clinical presentation (e.g. thyroid
  disorder, etc.)
• Possible exogenous factors contributing to the
• clinical presentation (e.g., drugs, etc.)

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New Description

• Psychological
• State of mind of the individual and their
  family
• Events impacting the presentation (e.g.
  trauma, incarceration, etc.)
• Style of the individual

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New Description

• Social
• Life circumstances (e.g. socioeconomic,
  living situation etc.)
• Level of Function
• Supports
• Legal
• Educational
• Spiritual
• Other
• Prior Assessment and Treatment
• Response to Prior Treatment

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Old Description

• Evidence Based
• What does this mean?
• We want evidence, but what is the evidence?
• How does a clinician take the evidence into
  account?
• What compels a clinician to consider the evidence
  and utilize it?
• How broad is the application of the evidence?
• When do we run out of evidence and have to rely
  on common sense?

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New Description
(from Gray, 2004)

• Evidence-Based
• Formulate the Question
• Search for Answers
• Appraise the Evidence
• Apply the Results to the Patient
• Assess the Outcome

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• Evidence-Based (continued)
• Track Improvement and Outcomes
• A Form of Services Research Built Into the
  Multidisciplinary Effort (i.e. what works and
  what does not work)

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New Description

• Treatment Algorithims
• Integration of Biological, Psychological and
  Social approaches using only what is most
  appropriate, what is needed, and what the
  evidence tells us to do
• Tracking Outcomes, Quality of Life, Function

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Old Description

• Culturally Competent What does this mean?
• Can only African Americans treat African
  Americans?
• Can only Asian-Americans treat Asian-Americans?
• Can only Hispanic-Americans treat
  Hispanic-Americans?
• Can only Caucasian-Americans treat Caucasian
  Americans?
• Can only First-Generation Americans treat
  First-Generation Americans?
• Can only Middle-Class Americans treat Middle
  Class Americans?

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• Can only women treat women?
• Can only children treat children? Etc.
• How about, for starters, we insist on just being
  competent?

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New Description

• Culturally Competent
• In providing care, clinicians must understand the
  beliefs that shape a persons approach to health
  and illness
• Knowledge of customs and healing traditions in
  the design of treatment and interventions

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Old Description

• Patient and Family Focused
• What does this mean?
• Does it really happen?
• What is meant by Focused?
• Is taking a history, doing an assessment, coming
  up with a diagnosis, translate into Patient and
  Family Focused?

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New Description

• Shared Decision-Making
• A basic principle of treatment, i.e., a
  collaboration

Consumer/patient
Treating System
Family

• Setting the tone early at the first visit

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New Description

• Multidisciplinary in scope
• Conscious utilization in a cost-effective manner
• Use whatever resources are directly necessary for
  the individual and their family

Nursing
Social Work
Public health
Psychiatry
Primary care
Psychology
Consumer/patient family
Legal
Educational
Occupational
Supports
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Old Description

• Transformation
• What does this mean?
• Transform like casting a magic wand and
  suddenly things are better?
• Transform because this concept is used, it
  means we all agree on what the transformation
  should be?

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New Description

• Turn the System Upside Down
• Consumer/Patient and Family are the Center of the
  attention
• But a caveat, if at the center , does this
  establish a dependent position unintentionally
  vs. shared decision making where the
  consumer/patient and family are part of the
  health care system?

Patient/Family
vs
Patient/Family
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Old Description

• Fee-for-Service
• Fee for what service?
• Piece-work and therefore fragmented
• By definition, not comprehensive and not
  integrated

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Old Description

• Capitation
• Still not integrated, not comprehensive covers
  only the medical health side

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New Description

• Need for New Economic Models
• Pay for Performance within a Quality Improvement,
  Cost-Effectiveness Paradigm
• Multidisciplinary a Requisite
• Outcomes and Follow-up Essential
• Fund Innovation Models

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Enter the Annapolis Coalition

• Charged by SAMHSA to develop a National Strategic
  Plan on Workforce
• A broad-based, consensus-building national effort
  focusing on pre-professional and the established
  workforce in the context of Consumers/Patients
  and Families, Children, Information Technology,
  Dual Diagnosis, Rural Behavioral Health,
  Integration with Physical Health, etc.

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New Description

• Multidisciplinary in scope utilizing a
  consciously cost-effective manner

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The Annapolis Coalition on the Behavioral Health
Workforce
Board of Directors
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The Annapolis Coalition on the Behavioral Health
Workforce
Steering Committee
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The Annapolis Coalition on the Behavioral Health
Workforce
Steering Committee (continued)
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The Annapolis Coalition on the Behavioral Health
Workforce
Consumer/Patient and Family Work Group Executive
Committee
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The Annapolis Coalition on the Behavioral Health
Workforce
Consumer/Patient and Family Work Group Executive
Committee (continued)
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New Description and Clinical Curriculum Reform

• Each discipline starts training by itself
• Build interdisciplinary seminars and clinical
  case conferences into the training experience
  focusing on the integration and coordination of
  care among disciplines
• Place multidisciplinary teams into clinical sites
  and have them function in the way they were
  trained
• Create Interdisciplinary Workgroups/Institutes to
  develop Innovation Models
• Study the Models and their Outcomes compared with
  treatment as usual

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New Description

• Developing a Strategy for Curriculum and Training
  Reform (Get Political!! Time for Return on
  Investment
• Identify Innovators
• Mobilize the Strength of the Respected National
  Advocacy Organizations to Work Together
• Press the Education and Training Establishments
  in each discipline to modify the way it educates
  and trains
• Focus on both pre-professional training and on
  the established workforce
• Develop funding systems that will drive and
  sustain innovation at the Federal and State Level