Collaborative care between nonphysician clinicians and prescribing physicians involves several benefits and potential problems. Standards of conduct on the part of each provider have not been established, yet joint care of patients between those who prescribe medication and those who provide psychotherapy is a common and growing model of delivery of mental health care. This article provides some practical guidelines for effectively managing the relationship between providers of collaborative care and their patients from the nonphysician clinician's perspective.
WHAT MOTIVATES NONPHYSICIAN CLINICIANS TO SEEK MEDICATION CONSULTATION?
A central motivation for a nonphysician clinician to seek medication consultation is the presence of conditions for which pharmacotherapy is the primary treatment of choice. Conditions such as bipolar disorder, schizophrenia, and other forms of psychosis lead most nonphysician clinicians to seek medical consultation promptly. However, a savvy nonphysician clinician will avoid dismissing adjunctive psychosocial interventions that can be helpful to many patients with these conditions.1,2 It is important to avoid quick referral to the prescribing physician without plans for providing appropriate psychosocial treatment. This situation can leave the prescribing physician in a difficult position, possibly without adequate time, expertise, or both to provide a combination of medication and psychosocial treatment, which is often optimal.
A second motivating factor for nonphysician clinicians to seek medication consultation is the preference of their patients. Many patients arrive at the clinic with the expectation that they will be offered medication. In this situation, clinical experience suggests that meeting a patient's expectations by providing medication is advisable. However, before medication is initiated, it is important to provide patients with a comprehensive review of interventions with empirical support for their condition. Obviously, there are circumstances in which a nonphysician clinician may advise against medication even though his or her newly evaluated patient requests it. For example, a man presenting with a height phobia who wishes to be treated with benzodiazepines may well be advised against using this approach in favor of a behavioral intervention with an established record of success.3
Another factor that often leads a nonphysician clinician to seek medication consultation relates to his or her personal experience with medications. If the nonphysician clinician has had favorable experience with a particular medication for a certain disorder, a referral for medication is likely. Conversely, negative experience can direct the nonphysician clinician away from seeking a medication consultation. The danger here is that personal experience can be held above empirical data in treatment selection. A wise nonphysician clinician will be cautious about the overuse of personal experience and will instead rely on research literature and clinical experience when formulating a treatment plan.
Another motivation for nonphysician clinicians to seek medication consultation is to gain help in confirming a diagnosis, formulating a treatment plan, or both. Obviously, these requests are more thoughtfully referred as diagnostic consultations rather than medication consultations. However, some nonphysician clinicians may feel uneasy about admitting uncertainty regarding diagnosis and treatment planning and may refer for medication consultation with the idea that diagnostic issues will be addressed during the consultation.
Nonphysician clinicians may also be motivated to seek medication consultation when they are not well trained to provide appropriate psychosocial interventions for a given disorder. This problem may lead nonphysician clinicians to use medication consultation as an intervention motivated by convenience rather than by the belief that medication is necessarily the best choice for their patients. Taking time to receive consultation and training in the appropriate intervention strategy or providing a referral to a qualified clinician is preferable to a referral for medication that is motivated by convenience rather than clinical indication. In some areas, convenience is not the issue; instead, the appropriate psychosocial treatment resources are truly not available. For example, good quality cognitive-behavioral therapy is often difficult to find outside of major cities and far from academic medical centers.
Nonphysician clinicians may also seek medication consultation because of patient characteristics that they see as predictors of poor outcome with psychosocial interventions. Patients with lower levels of intelligence, patients who are not "psychologically minded," or patients who are more severely impaired may be considered by nonphysician clinicians as unsuitable for therapy. Clinical experience suggests that these judgments can be made too quickly. Psychosocial treatments can be modified to be of help to unsophisticated patients or those with severe illness. However, this is not meant to imply that the severity of illness should not be taken into account when considering medication consultation. The empirical literature indicates that patients with certain disorders (eg, severe major depression) are often best treated initially with medications, followed by appropriate psychosocial treatment, if necessary.4
The failure of psychosocial interventions may also motivate nonphysician clinicians to seek medication consultation. When psychosocial treatment fails, medication is the logical next step for many patients. However, recent studies indicate that many patients respond similarly to medication, empirical psychosocial treatments, or combined approaches.5-6 Given these results, one can speculate that regardless of which empirically supported treatment approach is selected, certain patients respond to treatment, whereas others do not. Consistently referring for medication only those patients who have failed to respond to psychosocial treatment may disproportionately burden physicians with patients whose conditions will not improve. This problem can be eased somewhat when nonphysician clinicians give equal consideration to medication and psychosocial interventions at the time of initial treatment planning.
Patients whose symptoms are difficult to manage, including those with personality disorders, may be referred for medication consultation to reduce the burden of treating such patients. Although sharing the challenge of treating these patients can offer advantages, such as clinical consultation regarding selection of appropriate interventions and collaboration when problems occur, pitfalls can also be encountered when patients whose symptoms are difficult to manage are treated collaboratively. These pitfalls are especially likely to occur when co-treating patients with personality disorders. These patients are likely to position one provider against the other when treatment is shared. If the providers involved are sufficiently skilled, this problem may serve as a therapeutic opportunity. If the providers are not in close contact, or are not experienced in treating such patients, problems are likely. A medication consultation should be conducted if the nonphysician clinician has reason to expect that medication could be helpful, not as a method to ease the burden of treating patients with difficult symptoms.
The presence of a "VIP" patient in the clinic may also motivate the nonphysician clinician to seek medication consultation. Nonphysician clinicians are sometimes motivated to be especially thorough by offering all treatment options to this "special customer." This practice has clear ethical implications. Obviously, nonphysician clinicians need to be thorough in evaluating treatment options with every patient, and VTP patients should be referred for medication only if it is clinically indicated.
Patients with a history of filing lawsuits, or the presence of a clinical situation in which the risks of a lawsuit may be elevated can also motivate nonphysician clinicians to seek a medication consultation. Spreading the risk of a lawsuit to the prescribing physician may be seen as advantageous. Clearly, having more than one provider involved in the care of a patient may provide some measure of protection against making an error in diagnosis or clinical judgment. Additionally, the involvement of the prescribing physician protects the referring nonphysician clinician from the claim that a physician should have been consulted.
However, involving a physician may actually elevate the risk of a lawsuit. The presence of a physician may be viewed as an opportunity for greater monetary return in a lawsuit. Rightly or wrongly, the physician may be seen as having "deep pockets," making a patient's case more attractive to a consulting attorney. Moreover, the addition of a second provider may also elevate the risk of a lawsuit if that provider is guilty of unethical or incompetent practice. It is possible that the referring nonphysician clinician will be named in the lawsuit even if he or she practiced appropriately. When these issues are taken into account, the strategy of referring for medication consultation only when it is clinically indicated is the soundest practice for the nonphysician clinician.
WHAT DO NONPHYSICIAN CUNICIANS EXPECT FROM PRESCRIBING PHYSICIANS?
Most nonphysician clinicians have several expectations of the prescribing physician with whom they collaborate. Obviously, nonphysician clinicians expect the prescribing physician to seek information regarding diagnosis, current treatments, and reasons for referral when a consultation is initiated. The collaborative relationship is often greatly enhanced if the prescribing physician thoughtfully reviews this information with the referring nonphysician clinician. Referring nonphysician clinicians respond favorably when their professional expertise is valued by their physician collaborators.
Once the prescribing physician has reviewed diagnostic information provided by the nonphysician clinician, the obvious expectation is that he or she will make recommendations regarding the suitability of medications and will present this information to the patient. Within a collaborative treatment paradigm, if medication is prescribed, it is especially important that the prescribing physician clearly describe to the patient how he or she should take the medication. If there is some uncertainty, patients are likely to direct questions regarding the use of their medication to the nonphysician clinician. Clearly, the prescribing physician is in the best position to answer these questions. Written instructions regarding the use of medication, including expected side effects, can be especially valuable in a collaborative treatment relationship. These instructions can be helpful in reducing the chance that the patient will seek a consultation regarding dosing schedules or other specific issues related to the use of medication with the nonphysician clinician. Such detailed consultations are clearly outside the professional practice area of the nonphysician clinician.
Also, a clear plan of follow-up visits for a review of medications must be in place for a collaborative treatment arrangement to be successful. Additionally, reasonable access to the prescribing physician via the telephone is important. One of the most frustrating situations a nonphysician clinician faces is when the patient runs out of medication and the prescribing physician is not available. In this instance, patients often contact the nonphysician clinician for assistance. This can be especially problematic when medication is needed promptly, such as when a patient has just taken his or her last tablet of a benzodiazepine and is at risk for seizure if he or she does not get resupplied quickly. The situation is often exacerbated when the prescribing physician does not return phone calls or is rarely available for telephone consultation. It is obviously important in a shared treatment relationship that an adequate supply of medication be maintained.
However, it is also important for the nonphysician clinician to avoid the assumption that the shortfall in medication supply is the fault of the prescribing physician. In addition to misusing medication, patients can also fail to meet their obligations in scheduling appointments and appropriately caring for medications and prescription forms. For these reasons, nonphysician clinicians faced with a patient who is reporting a problem with his or her supply of medication should refrain from joining the patient in complaining about the prescribing physician. When supply problems arise, the nonphysician clinician may wish to seek out the prescribing physician personally in an attempt to solve them.
In addition to educating the patient about his or her medicine, supplying the patient adequately, and being available for patient consultation, the prescribing physician also has important responsibilities related to the psychosocial treatment plan. It is especially important for the prescribing physician to refrain from making suggestions for change in the psychosocial treatment plan directly to the patient without prior consultation with the nonphysician clinician.
Patients are likely to ask the prescribing physician for his or her opinion regarding the nature of their psychosocial treatment. They often see the prescribing physician as the best trained and most respected source of information regarding all aspects of their care.7 It is preferable, in most cases, for the prescribing physician to respond to questions regarding the patient's psychosocial treatment plan with phrases such as, "Did you discuss this issue with your therapist?" or "I will consult with the therapist and get back to you." This practice is particularly important for patients with personality disorders, who are often persistent in questioning the prescribing physician. This problem can be especially troublesome when the prescribing physician is the adininistrator of the clinic and is in a position of authority over the nonphysician clinician, clearly creating fertile ground for manipulative behavior.
However, this does not mean that prescribing physicians should take a "hands off" approach when dealing with emotional and interpersonal problems or delivering psychosocial treatment. Prescribing physicians who have a good understanding of the issues of importance to their patients and who form supportive relationships with them will be more effective providers. Additionally, providing complementary psychosocial interventions in collaboration with the nonphysician clinician can be a helpful strategy for some patients.
A final expectation of the referring nonphysician clinician relates to the manner in which the prescribing physician represents the potential utility of the psychosocial intervention plan. Patients are often resentful when promised something that is not delivered. Prescribing physicians should avoid overselling the potential benefits of psychosocial treatment. Obviously, no intervention strategy is universally helpful. Presenting the potential merits of psychosocial interventions with cautious optimism is usually best. Conversely, prescribing physicians should avoid pessimistic comments about the psychosocial treatment plan because these can interfere with patient motivation and subsequent treatment outcome.
WHAT SHOULD PRESCRIBING PHYSICIANS EXPECT FROM NONPHYSICIAN CLINICIANS?
A shared treatment relationship will also be greatly enhanced if the referring nonphysician clinician meets the expectations of the prescribing physician. Clearly, the prescribing physician is not in a position to provide medical care if the information he or she receives regarding the diagnosis and the clinical history is incomplete or inaccurate. A carefully written, complete, and accurate report is of great value to the prescribing physician, given that medication consultations do not usually include enough time to conduct a second, complete psychiatric evaluation. This report should clearly articulate the reasons for the medication consultation. Beyond the written report, a brief telephone consultation initiated by the nonphysician clinician is often of great value.
A second issue regarding the relationship between the nonphysician clinician and the prescribing physician relates to the manner of referral to the prescribing physician It is important that the nonphysician clinician refer his or her patients for a medication consultation with the understanding that it may or may not result in their receiving a prescription. Nonphysician clinicians should refrain from referring patients to the prescribing physician to "get medications." Avoiding this practice comfortably leaves the decision about whether medication is indicated to the person best trained to make it. Just as the nonphysician clinician appreciates respect for his or her area of expertise, referring for a medication consultation with the understanding that a prescription may not be given communicates respect for the expertise of the prescribing physician
It can also be frustrating for the prescribing physician to consult with a patient who has been told to seek a particular medication, dearly,- it is the responsibility of the prescribing physician to present pharmacologic treatment options to the patient. It can be difficult to persuade a patient who has been told to seek a particular medication that another medication would be a better choice, especially when the recommendation has been made by a trusted nonphysician clinician. Conversely, it can also be problematic when patients have been warned against using certain medications by the nonphysician clinician. On occasion, nonphysician clinicians have negative biases regarding certain medications (eg, benzodiazepines) that can lead them to discourage their patients from considering them. These opinions are often based on clinical experience and not on research literature regarding the appropriate use of these compounds.
However, the nonphysician clinician can play a role in the medication selection process. Clearly, when the nonphysician clinician refers a patient with a history of substance abuse problems, communicating this to the prescribing physician is critical because this information will play a role in the selection of medication. Additionally, nonphysician clinicians who have extensive knowledge about medication treatment of a particular disorder can play a role in the selection of medication.
As with advice about psychosocial treatment offered by prescribing physicians, medication recommendations are best made directly to the prescribing physician rather than indirectly through the patient. It is not uncommon for patients to persistently ask the nonphysician clinician to give "an opinion" about their medication treatment. In such cases, nonphysician clinicians may best respond by using a phrase such as, "I know your medication is important to you and because of this it would not be helpful for me to make specific recommendations about your medication when your psychiatrist is better able to advise you."
Maintaining close communication is another important expectation of the prescribing physician. The nonphysician clinician is often the first to observe clinical regression, potentially dangerous side effects, or medical problems. These developments may have important implications for medication treatment and this information should be communicated promptly. Conversely, it is equally important for the prescribing physician to communicate changes in a patient's condition to the nonphysician clinician.
SHARED PROBLEMS AND REWARDS
One problem that can present itself in collaborative care is a patient complaint about the other provider. Obviously, complaints can be directed toward the prescribing physician or the nonphysician clinician. It is important for the provider who is receiving the complaint to listen attentively to the patient's concerns. In many cases, the best practice is to encourage the patient to discuss these issues with the provider in question.
The provider who is receiving the complaint should avoid offering an opinion about the actions of the other provider. If the complaint is serious, the provider who is receiving the complaint should note it in some detail and inform the patient that he or she will discuss it with the other provider before commenting further. Joining with the patient in complaining about the behavior of the other provider is legally unwise, and there is little to gain clinically from this practice. If the behavior of the other provider appears to be grossly negligent and outside the ethical standards set forth by his or her profession, then it is the responsibility of the provider who is receiving the complaint to take whatever actions are necessary to protect the right of the patient to receive appropriate care.
It is valuable to have a good working relationship with one's professional collaborator when a complaint is lodged by a patient. If a patient makes a complaint in a collaborative treatment situation and there is a long-standing positive professional relationship between the providers involved, the outcome is likely to be favorable. If the providers do not know one another, or, worse yet, if the personal or professional relationship has been a negative one, the outcome is more uncertain. The obvious recommendation is to collaborate as much as possible with familiar providers with whom the professional relationship is positive.
Another problem that is related to patient dissatisfaction is the temptation for the favored clinician to begin to provide services that the disfavored provider is contracted to provide. When relations are strained between the patient and the prescribing physician, the patient may begin to rely on the nonphysician clinician for medication advice. Similar problems can develop when difficulties are present between the patient and the nonphysician clinician. Prescribing physicians can find themselves feeling pressured to fit both medication review and psychotherapy into a visit schedule designed for medication management.
Problems of this sort can be transient and the patient can often be prompted to discuss them with the disfavored provider. If this suggestion fails, the favored provider may wish to intervene by contacting the disfavored provider with the hope of repairing the relationship. As a last resort, the favored provider may need to assist the patient in replacing the disfavored provider if the relationship is strained beyond repair.
Status issues can also present as potential problems in shared treatment arrangements. It is important for each provider to avoid the lure to compete for proininence in the eyes of the patient. Some providers make comments that are designed to inflate their standing with the patient. They characterize themselves as the provider with the best framing and the most experience or the one in primary control of the patient's care. Shared treatment is best conducted when the providers involved are seen as equal partners, working together in the best interest of the patient. Obviously, it is impossible to eliminate status issues from the shared treatment relationship. Factors such as age, years of experience, clinical style, and professional degree can lead a patient to favor one provider's opinion over the other's. However, providers can avoid fostering these preferences by refraining from comments designed to inflate their own status at the expense of the collaborating provider.
There are several shared rewards when two providers are involved in the treatment of a patient. If communication lines are open, clinical consultations often yield improved treatment programs. For instance, the nonphysician clinician could be helpful in encouraging patients to take their medications as prescribed. Psychosocial interventions/ particularly cognitive-behavioral interventions, can be helpful in enhancing medication adherence.8 Conversely, the prescribing physician can encourage compliance with the psychosocial treatment plan. With patients whose symptoms are difficult to manage, the two providers can present a united front in rewarding acceptable behavior and redirecting inappropriate behavior. Additionally, collaborating with another provider can be helpful in buffering stress when treating a challenging patient. Finally, a collaborative care model can result in improved access to clinical care when a provider is on leave or when urgent help is needed during a crisis.
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