Trying to do the Right Things

I remember my mother's psychiatrist, years ago, telling me that the doctors in his profession were leaving the field in droves. This article is one of the reasons why. Most doctors have a conscience and try to do the right thing with their patients, but either families or the laws get in the way of treatment that makes sense. I see that the problem still exists.

IMAGINE YOU live in a small town, and your son is found to have a brain tumor. Faced with such a devastating illness, you would not hesitate to find the means to get to a medical center, even if it were in a city more than an hour from your home. You probably would search for high-quality specialists to provide the best care possible.

But consider that your son has another serious illness affecting his brain, but one you cannot see on a scan. I am referring to serious mental illness. Rather than assuming that this child deserves to have access to the same specialized care, our culture has colluded in the belief that a primary care doctor will be an acceptable provider of care.

As a pediatrician I take care of many children diagnosed with attention deficit hyperactivity disorder. For this problem I consider myself well qualified to provide excellent care. But often, what starts out as a diagnosis of ADHD proves to be much more complex. One child (I have changed details and combined stories in order to protect the privacy of my patients) did well enough for several years, but began to display increasingly angry and aggressive behavior. I made multiple adjustments in her medications, all along expressing concern to her mother. There were many obstacles to getting an appointment with either a therapist or child psychiatrist, so I continued to treat her.

Then one day, she told me she was so angry that she feared she would hurt someone. I notified the local crisis team, making it clear that I knew this family very well, that I was worried about her, and that I wanted to be called after she had been seen. No one called. They simply referred her back to me to adjust the medication.

Now I was both worried and angry. I called the one local psychiatrist who accepts the family's insurance. He told me that until he could be sure that the patient's insurance would go through, "she's your responsibility." I explained to him (not in a nice voice) that I had reached the limits of my expertise, that this girl and I both needed his help. After more days of multiple calls, she had an appointment with both a therapist and a child psychiatrist.

Another patient who had a history of severe abuse as a young child followed a similar course. For several years he did OK on his ADHD medication. But he began to fail in school. He was extremely anxious. After a particularly explosive and frightening scene that included threats of self harm, I told his mother that I was referring him to a child psychiatrist.

After jumping through multiple hoops, I was able to find a psychiatrist who had room in his practice. Yet a month later, I got a message in my office requesting a refill of his medication. I called his mother to clarify my plan to transfer his care to a child psychiatrist. She was upset that the psychiatrist's office was an hour away and wanted to keep things the way they were. When I again explained that her son needed more help than I could offer, she yelled at me, "You're just leaving us out in the cold!"

So how have we gotten to this unfortunate situation where primary care doctors, who are clearly not qualified, are expected and encouraged to treat children with serious mental illness? I believe three main factors are at work. First, the pharmaceutical industry has been successful at promoting the idea that a pill will fix these often complex problems. Second, the insurance industry has made it very difficult for primary care doctors to refer patients for any mental health services. And third, there is a severe shortage of child psychiatrists.

Together these factors have converged to back us into a corner. If primary care doctors do not provide this care, the child will not get care, and we will be in effect abandoning our patients. This is an unacceptable situation. We must address this problem on all three fronts in order to ensure that these seriously troubled children have the same access to care as a child with a brain tumor.

Dr. Claudia Gold, a pediatrician, practices in Great Barrington.