Can medical practice adapt to a changed world

In this issue of World Psychiatry, Sir David Goldberg outlines why, over the last fifty years, primary care has become the modal care setting for common mental disorders, and why it is likely to assume an increasingly important role in caring for persons with chronic, severe mental disorders. Like other common chronic medical conditions (e.g. diabetes, asthma, heart disease), there is an epidemiological imperative for care of most persons with common mental disorders to occur in the primary care setting (1). This is due to the sheer numbers of persons with these disorders, the relative accessibility of generalists versus specialists, and the preference of many individuals for care from their personal physician. The last fifty years have witnessed revolutionary societal and technological changes that have accelerated community care of mental disorders in primary care settings. In the 1940s, the monthly cost of mental hospital care and of income maintenance programs for the disabled were roughly equal. Hospital care became prohibitively expensive relative to disability payments in the ensuing decades, accelerating the trend towards community placement of the severely mentally ill. Effective drug treatments for schizophrenia, major depression and bipolar disorder were discovered mid-century, while the diversity of effective drug treatments for these disorders increased markedly in the 1970s and 1980s. Publicly financed health insurance emerged in the wake of the Second World War, and expanded rapidly thereafter, contributing to a rapid increase in use of medical services. The number and diversity of mental health professionals increased dramatically, insurance coverage for psychiatric treatment became common, and the general public became more accepting of mental health treatment. Over this fifty year period, effective drug treatments were discovered for a wide range of chronic conditions, making medical practice more complex and more essential for health maintenance of the chronically ill, including persons with mental disorders. We are now witnessing the emergence of consumerism in health care, including increased emphasis on shared decision-making, activated patients, patient-rights organizations, and (in the United States in particular) direct marketing of drugs and other treatments to the general public. In the face of these revolutionary societal and technological changes that have transformed the context of health care, the practice of medicine has remained mired in traditional, ineffective practices. Physicians continue to embrace traditional ways of organizing and providing care despite extensive research showing that routine care is of embarrassingly poor quality (2). Patients prescribed medications for ongoing management of major chronic disorders typically take less than half of the prescribed dose (3). It is commonplace for less than half of the patients started on a new treatment regimen to carry out the treatment in a manner that satisfies evidence-based guidelines. Generalists and specialists remain wedded to the traditional medical encounter in which diagnostic evaluation and initial treatment selection are emphasized, while monitoring treatment over time is left to chance. Care is not organized to ensure active follow-up of chronically ill patients over time, to tailor treatment regimens to patient differences in treatment response or side effects, or to support patient selfmanagement of complex therapeutic regimens (4). To improve care of chronic conditions, primary care physicians need stronger support from specialists in managing complex cases, and from allied health professionals to ensure active follow-up and to fully engage patients in self-management of their illness (5). Unfortunately, specialty practice too often remains isolated from primary care in hospitals and specialty centers, with structural, cultural and economic barriers to closer collaboration with primary care physicians. Well organized care management services for patients with major chronic conditions remain the exception rather than the rule. David Goldberg points to progress in the integration of specialists and allied health professionals into primary care in the United Kingdom, but the scope of these changes is not yet in proportion to the magnitude of the problem. Innovations in care in the United States trail far behind developments in the United Kingdom, despite substantially greater per capita spending on health care in the United States. It is only human nature that physicians are wedded to traditional ways of organizing and delivering care, despite abundant evidence that traditional ways of practicing medicine are seriously deficient. Changing deeply ingrained practices in professional organizations is difficult and slow. Traditional medical practice is failing to meet the needs of chronically ill patients, those with medical as well as those with psychiatric illnesses. If the health of chronically ill patients is to be maintained, fundamental changes in the organization of medical care are needed to ensure that patients are able to achieve the best long-term outcomes possible with available treatments.