I recently read an article in the Economist about over-prescription of antidepressants. The essence of the article is that antidepressants of various kinds appear to be very effective for about 15% of patients and of no more impactful than a placebo for the remainder. Based on that, it notes genetic profiling should one day be able to precisely identify those patients for whom this class of drugs is effective and limit prescriptions to this cohort.
I expect I had a different take away than the author intended. What struck me (and it ties into the integrated care model we have at Crossover) is that antidepressants are the default solution for physicians when they don’t have a solid connection with or access to a mental health provider. Not just a list of specialists to refer to, but a genuine close working relationship that is part and parcel of a high-performing care team. Instead, you have physicians operating in silos and, when outside of their area of expertise, “reflexing over” this gap with a prescription. Now, if the antidepressants could be shown to be working 100% (or heck, even 50%) of the time I might buy into their indiscriminate use, but at only 15% efficacy it feels unacceptable.
Alternatively, for a physician who practices in a Primary Health care model like Crossover, where it’s simple (and in fact expected) to collaborate with allied professionals like mental health, it’s quite likely the clinical pathway would not be to prescribe first, or possibly at all. The default action for the integrated care team physician is to reach out to our embedded mental health provider. In our experience over the last decade, most of our members both appreciate and respond positively to their care team being genuinely interested in getting to the root cause of their problem, instead of just pushing prescriptions while pushing them out the door. The ability to take time with a care team before reflexively prescribing is not only good medicine, but best practice and central to creating trust, engaging patients, and building relationships that lead to better outcomes.
It got me thinking about how much importance is appropriately attached to patient engagement, and unfortunately how little to provider engagement. While the best and brightest are attracted to medicine, both their education and their experience after graduation teaches them little about partnership and collaboration with allied health professionals let alone with their patients. If a primary care physician has a great rapport with her patients, it’s more often a factor of her character and personality, not an intended outcome of specific training.
Between the pandemic, the increased administration burden of digital health tools such as EHRs and the ever-decreasing payments, the disengagement of physicians we’ve been reading about for years has only accelerated. Physicians were taught in school and trained to think they need to be all-knowing sages, but the modern reality doesn’t align with this outdated notion. Providers often don’t always have the experience, work in an integrated practice model, or have the time in their day to day practice to reinvent themselves as collaborators. Many run the hamster wheel until both mental and physical exhaustion causes them to check out for good. Even for those who stay to gut it out, practice becomes a relentless and unfulfilling grind, where they finally succumb to the default practice of just referring or prescribing their patients away. This normalization is not okay.
Service Design teaches us to care for the employees, who can then best care for the customer. Health Service Design can learn and should apply this same art. The beauty of truly embracing a care team model for physicians is that they can become human again. They can count on their care team peers to provide second opinions and add to a diagnostic or therapeutic plan in new and unexpected ways. They can see their patients succeed as multiple disciplines contribute to their care journeys. They can share the wins, and the burdens, with a team working together through challenges. They can become deeply engaged in the art of “practice”, and practice this art for maybe for the first time in their career. Whle member engagement captures the headlines, provider engagement–as catalyzed through a care team structure–captures the hearts and minds of those delivering the magic day in and day out.
Scott Shreeve, MD 