By Kim Wyman MAPS, Executive Director, Melbourne Division of GPs,
with David Stokes, APS Manager Professional Issues
FOR MANY psychologists, finding common ground with GPs may be a 'yawn yawn' issue, since they have worked closely and successfully with local GPs for years. Many psychologists will have learnt, or naturally expressed, ways to negotiate and collaborate with the medical model as practised by GPs. So for these readers, this article may not be informative, but may present an opportunity to share your experiences with InPsych. For the rest, take careful notes.
One of the consequences of the recent initiatives in mental health such as Better Outcomes in Mental Health Care (BOHMC) is that GPs will be the gatekeepers of funding of psychology services to the clients of primary health care. The current 16 pilot projects around Australia are just the start of the expected availability of evidence-based interventions from psychologists and other allied health practitioners. It is therefore vital that psychologists know how to deal effectively and appropriately with GPs to ensure the best services for their clients.
So what follows is the accumulated wisdom of a psychologist who has worked closely with both GPs and other psychologists for years. The basic issues and principles necessary for psychologists to consider are set our under three headings.
Respect for the medical model
Many GPs still entertain the notion that present-day psychologists are anti medication and anti medical model. This has grown from the high-profile views of Laing and others, as well as the often-expressed concern of psychologists about stimulant or other medication. As a result, GPs need to know and hear from you that you are respectful of their professional practice and prepared to work collaboratively and even to support the patient continuing with their medication.
There is, of course, good evidenced based research showing that the combination of psychological and pharmacological interventions can be the most effective means
of managing disorders such as depression, anxiety and Oppositional Conduct Disorder. GPs need to be persuaded that you are prepared to work alongside them and are not intending in any way to undermine or compete with them.
Respect for the referral process
When GPs refer to other specialists, they do so with a letter that sets out the client's needs, their formulation of the condition and some expectations of specialised treatment. The referred-to specialist will then see the patient and promptly respond with a letter or some form of communication which politely thanks them for the referral, describes their formulation and their treatment plan. At the same time they refer the patient back to the care of the GP, describing the limits of their involvement
It seems superfluous to say that the process is courteous, respectful of who owns the client and makes obvious the vital need for full communication. It is alarming how often non-medical practitioners do not follow these culturally appropriate procedures.
Be realistic about the pressures on GPs
The Wyman Law of working with GPs says that for any endeavour with GPs, you can safely predict that behaviour will fall into one of three classes:
The first group, who tend to regard themselves as procedural GPs, will refer patients with mental health issues to psychiatrists. Depending on the area and accessibility of psychiatrists, a very small number of the BOHMC-accredited GPs may come from this group to provide their Health Care Card and other patients with subsidised access.
The second group, also likely to be under-represented amongst BOHMC-accredited GPs, may be deterred by the volume of new information, complex paper-work requirements or inadequate familiarity with psychological treatment modalities.
The third group will be mainly GPs who agree that GPs undertake counselling with patients as an essential element of general practice. But beware. There is no common ground about what methods constitute counselling. Direct giving of advice about risky behaviours is regarded by some GPs as counselling.
These categorisations do not constitute a cheap shot at GPs. It is a realistic view that regardless of their intentions, they are easily swamped by the reality of their client load. But it has two important outcomes for psychologists.
Firstly, approach GPs with an awareness that mental health or psychiatry is in left field for most. Present your services and opportunities in terms that make sense to them - particularly in terms of client needs. (Most GPs will complain when they receive detailed clinical reports - from psychiatrists or public hospitals for example - without a lead paragraph synopsis including a treatment or medication plan.) So when meeting for consultation or feedback, try to meet with GPs in their rooms to address the GP's needs and assist with client expectations.
Secondly, when considering the BOMHC program, recognise that only a small number of GPs are going to take advantage of this initiative and will not present competition, but access to Federally supported funding. Even those GPs who go beyond basic assessment-level training and do therapy training will mostly want to refer such patients on to psychologists or others.
For those psychologists who want to capitalise on the BOMHC, do the following three things:
Kim Wyman is a psychologist who has worked in primary care - until 1990 as Head of Community Services, Monash University (Caulfield Campus). Since 1994 he has been Executive Director of the Melbourne Division of GPs, which is the second largest division in Australia as measured by the number of GPs, although one of the smaller Divisions measured by area and resident population numbers. The general practices in inner-Melbourne are mostly solo or very small. His ideas are constructed from a phone conversation with David Stokes.