Psychiatry and Primary Care: Natural Partners

I come to my psychiatry training from a perspective that is a little bit different from most of my colleagues. What makes my perspective unique is that I’ve already had a career in medicine; I was board certified in family medicine prior to coming to psychiatry. This added perspective has allowed me to enjoy a special view of psychiatry as I’ve spent my fourth year serving as chief resident in the primary care psychiatry unit at Beth Israel Deaconess Medical Center.

My work as a family physician was based on a simple premise: be interested in my patients, in their total lives—as parents, partners, workers, children, pilgrims in life—and use that understanding to provide more personal and thus more effective medical care. I cared for my patients from birth to death, always mindful of the contexts in which they lived their lives. My work was a “relationally based practice,” founded on an intense interest in my patients as people.

Psychiatry is similarly “relationally based.” We are keenly interested in our patients’ lives, not only in the present but historically. We become fascinated with the ways that they, like us, were formed and de-formed as they lived their lives and how it is that they have become stuck along the way. Our tools are many, but the basis of our healing work is to apply our knowledge of medicine and psychology in the context of a collaborative relationship. Tending to the relationship is no less critical for our success as psychiatrists than tending to the medical and psychological aspects of our patients’ struggles.

So it seems that one distinction between primary care and psychiatry can be summed up rather simply. Primary care seeks to care for patients in terms of their medical ills informed by knowledge of their psychosocial selves. Psychiatry seeks to care for patients in terms of their psychosocial ills informed by our knowledge of neurophysiology and medicine.

The practice of “primary care psychiatry” is no more clearly demonstrated than in the clinic in which I serve. Psychiatrists work alongside primary care internists in the same clinic, using the same staff, under the same financial constraints of practice. Primary care doctors, nurses, and ancillary staff meet together weekly with psychiatrists and social workers to share our struggles and successes. It is a time when a common view can be fostered.

What results is a community of caring professionals who use their individual strengths to help one another care better for our patients. As a result of working in this tightly functioning group, especially as a primary care doctor myself, I have come to understand in a keen way what our primary care colleagues need of us—and what we need of them—in today’s managed care world.

Though we are both relationally based, our expertise differs. Our primary care colleagues need our help understanding the intricacies of the doctor-patient relationship. Ideas of transference, countertransference, the “sick role,” repetition, and defense are among the important areas of experience that we must bring to the table as we discuss care of our patients. We can help our primary care friends understand how to use themselves as highly effective tools of healing, through an empathic ear and a willingness to come to grips with our patients’ emotional pain.

My primary care colleagues need help understanding and accessing the mental health system. Our world often seems foreign and aloof to them. We can be an important liaison between worlds, helping them negotiate the sometimes convoluted world of mental health care.

We also provide an invaluable expertise about psychiatric medication. We prescribe and monitor patients’ responses to these medications every day. We know the difference between the pharmaceutical company claims and clinical reality. We must be a voice of clinical experience and reasonable expectation with regard to these agents, since studies tell us that our primary care colleagues prescribe in far greater numbers than we.

So what can we learn from primary care? My practice of psychiatry is somewhat different from that of my fellow mental health professionals. I feel more comfortable in a flexible response to a patient’s need. Providing care by brief phone calls, or in extended office visits, or even time-honored house calls are all comfortable parts of my practice. I feel particularly well trained to be a part of a multidisciplinary team and to work as a coordinator of care. I find I’m interested in the physical part of my patients’ suffering—how it is expressed somatically—as well as intrapsychically or relationally. I understand the importance of preventive care and can re-view my efforts to encourage mental health as well as treat illness.

The worlds of primary care and psychiatry are made to be complementary. Our primary care colleagues dearly want our involvement to help care for our common patients. Let’s work together to lower the barriers of tradition, finance, and time that have prevented these two powerful disciplines from joining forces more effectively for our patients’ good. ▪

Dr. Strong is an APA/GlaxoWellcome fellow and president of the GlaxoWellcome Fellowship Program. He is also a certified family practitioner and a psychiatry resident in the Harvard Longwood Psychiatry Residency Training Program.