There were important limitations. The patient population from this small academic medical center may vary from that seen in different clinic types, and its physicians may differ in their referral practices. Although it is possible that our results are unique to the CPC and not generalizable, the similarity of our patients to those reported in the survey literature of primary care strongly suggests that these are indeed the types of patients who would be referred to and attend such clinics elsewhere. Patients also were mostly white, so the results may not apply in other populations. Further, some reports indicate using unstructured records from the EMR alone for diagnosing depression has significant limitations [35]. We did not have structured data, and the quality of documentation cannot be assured. A further limitation is that we did not verify our findings by talking with the physicians or with the patients, nor did we use formal diagnostic tools administered to patients, such as the World Health Organization Composite International Diagnostic Interview [36], to establish independently our DSM-V diagnoses [22]. Nevertheless, CPC diagnoses were made by experienced clinicians familiar with DSM-V.
Conclusion
This descriptive research demonstrated the clinical presentation of behavioral health patients when consultation was provided by medical physicians in their usual clinic. We have identified the types of patients for which educators may want to prepare their residents (and students) and for which practitioners can seek continuing education. Specifically, we demonstrated that learners will need to know how to diagnose and manage patients presenting with many different physical symptoms, often difficult to explain on a disease basis. Further, they will need to recognize that the usual mode of presentation of a primary care behavioral health problem, typically underlying depression and anxiety, is with multiple physical symptoms [37]. Learners will, in turn, need to be taught the relational, cognitive behavioral, pharmacologic, and teamwork principles that must be used in treatment [37].
Nevertheless, practically speaking, training practitioners has been ineffective [38], and training residents and students would not yield results for many years, Thus, these data also highlight the need for increased training of consultation-liaison and other psychiatrists. The well-established success of collaborative care [39] warrants increased support, as do related team efforts such as the patient-centered medical home. As well, more support for services and implementation research is badly needed to facilitate behavioral care in the medical setting.
The well-trained physician of the future can greatly complement these current efforts. If we can address all the multiple factors involved, we can look ahead to a much changed behavioral health care scene in 10 to 15 years [40].
Acknowledgements: The authors would like to acknowledge key advisory roles played by the following parts of our team in developing this project. Heather Spotts, MSW, advised and participated in team management. Jose Herrera, MD, was crucial in providing psychiatry continuity in the Complex Patient Clinic. Carmen Meerschaert, MD, played a key initial role in developing the structure of the Complex Patient Clinic. Geraud Plantegenest, MS, was responsible to developing and ensuring the function of our internet technology work in the Complex Patient Clinic.