Guarding clients’ medical safety as a non-medical provider
Several years ago, my husband came home from the dentist and reported that he had high blood pressure at the time of his visit. He’s a doctor in internal medicine and he was surprised that his dentist’s office thought to screen for blood pressure at a semiannual checkup. We bought a home blood pressure cuff and he tracked his pressures for a few weeks and ultimately, the numbers coming back didn’t point towards medical treatment but if they had, that visit may have saved him months or years of untreated high blood pressure. Blood pressure wasn’t an inherently dental matter but a screening at the dentist could have alerted us to a larger problem.
As mental health practitioners, we see clients frequently and have many opportunities to spot early signs of medical problems but so many colleagues have reported to me that they feel uncomfortable with providing directive and specific referral guidance for fear of overstepping their license by dispensing medical advice. I believe it’s not just in our scope to provide appropriate referrals when we spot a possible problem, but that it’s an ethical obligation to become better at doing so.
The false dichotomy of a brain/body divide
Mental health problems are medical problems (in part) and most other medical problems have some influence on mental health. At minimum, mental health clinicians should have some medical knowledge on disorders and symptoms that cross the brain/body divide. Insomnia, panic attacks, low mood, anxiety, agitation, pain, stomach and bowel trouble, skin picking, and even OCD have plausible explanations on both sides of the fence: Medical and mental health. While mental health clinicians cannot step over the boundaries of their licenses, they can be aware of concerning medical symptoms and ask clients to bring those symptoms to the attention of their physicians. I’m advocating for mental health clinicians saying something like, “I am aware that several common and treatable medical conditions can cause symptoms that look just like depression. It’s been awhile since you last had a good checkup and I would like you to meet with your doctor to rule out medical causes for this fatigue and low mood,” not, “I think your thyroid is messed up or maybe you’re anemic.”
How do we refer, encourage, or require clients to seek medical evaluation?
I would love to share a decision-making algorithm floating around in my head about how to do referrals, but it’s proving more difficult to get down on paper than I’d imagined. So for today, I just want to share a few common questions and statements I use to help clients engage fully in taking care of their health.
Do you have medical insurance? Do you understand your plan and feel comfortable using it? Have you foregone any medical treatment in the last year because of cost or coverage issues? Before I consider any referrals, I want to make sure my client understands their plan. If they don’t have a plan, I want to outline coverage options that may be available to them including Medicaid and Affordable Care Act plans. All of the referrals in the world don’t help if the client can’t afford to act on them and I see it as my duty to at least inform the client of options to get their health care paid for.
Do you have a primary care physician (PCP)? When I say PCP, I mean a Medical Doctor (MD) or Doctor of Osteopathy (DO), or a midlevel provider working in office with those physicians, usually with specialities in Internal Medicine, Family Medicine, or Pediatric Medicine (for children). Why those types of PCPs?
Administrative reasons. They are insurance-approved gatekeepers in the healthcare system. Most traditional PCPs have office staff who can check benefits, do disability paperwork when needed, and facilitate payments. They are also typically the lowest-cost providers on many insurance plans. Often, their offices use electronic health record (EHR) systems that connect to other doctor and hospital EHRs, enabling visibility of a client’s complete medical record at each visit, reducing the need for redundant testing or ordering cumbersome paper records.
Referrals to specialists they know. Many traditional PCPs have relationships with specialists to whom they can make appropriate referrals. They may have worked next to them at another job or trained with them in residency, so the recommendations are personal.
Evidence-based care. Traditional primary care physicians typically reference nationally- or internationally-accepted guidelines of care in their decision-making, which may sound rigid but it provides a framework for ensuring patients get an appropriate standard of care. For example, I recently talked with my doctor about the differing recommendations on mammograms from the US Preventive Services Task Force (USPSTF) and the American College of Obstetrics and Gynecology (ACOG). She talked me through the different guidelines and made a recommendation based on my personal and family history.
Experience with the worst. No doctor makes it through residency without patients dying. Anyone who spends three or more years in a hospital has seen some awful stuff. Most of my physician friends have had to take someone off life support. They bring that gut sense to the clinic and so I trust their assurances when they say “I feel safe treating these symptoms as behavioral rather than medical.”
Scope of practice. Most PCPs can treat a wide range of concerns including preventive care, minor procedures, prescribing (including quite a bit of mental health prescribing), and if they run into something they’re not comfortable with, they can refer. AND they often have the office staff to facilitate referrals.
Other practitioners are also valuable. My acupuncturist saved my quality of life when I went through a period of getting 4+ migraines a week and the next step, from my MD, was anti-seizure medication that wasn’t compatible with the pregnancy I was planning. I call my chiropractor whenever my back goes out (hello middle age, this is a thing now). My cousin is a naturopathic doctor and she always shares a ton of wonderful knowledge with me. I do not dislike “alternative” medical practitioners. I just want an MD or DO to tell me I’m not dying or seriously ill before I work on quality of life issues with the rest of my health team.
Have you seen your doctor in the last two years, about your general health? Have you talked with them about the concern we’re discussing today? If not, and assuming my client has insurance coverage and a doctor, I will ask them to see their doctor and describe their symptoms to see if there is any possible medical reason for those symptoms. I also encourage clients to say, “I am working with a counselor on depressive/anxious symptoms but she wants to be sure you feel reasonably confident that these symptoms cannot be explained by another medical issue.” Additionally, this conversation gives the physician a chance to discuss any medication options available to the client should they be interested in pursuing them today, or in the future. If that client has symptoms that would benefit from seeing a psychiatric specialist (a Prescribing Mental Health Nurse Practitioner (PMHNP) or psychiatrist), their doctor also has an opportunity to help make the referral using the resources they have in their office staff. A clinic social worker may be able to find a client someone in network with their insurance, which is very hard to find looking on your own. Some doctors even have prescribers in residence at their clinic, making medications consultations easy and usually much less expensive than seeing an outside provider.
Scripts for common scenarios
How do we actively direct clients to the care they need, without overstepping our professional boundaries? Here is how I direct clients in some imagined circumstances, below (using my name as the patient).
Twenty-something client needs a medication evaluation. “Hi Katie. I notice your anxiety has been so persistent and intense in the last few months. It’s been nearly impossible for you to engage in the homework we’ve talked about. In the past, you mentioned that you’re willing to talk with someone about medication options and I think now might be a good time to do that. To date, you’ve been using urgent care for most of your primary care needs. Given what’s going on, I would love to get you in to a primary care doctor who can rule out any reasonable medical causes for this persistent anxiety and talk you through options they could make available to you for better supporting your anxiety. Would you be open to that?” “Maybe I should just find a psychiatrist?” “That’s another reasonable option but I’m aware that that your insurance plan has a limited list of in network prescribers. Some clients find that it’s a good use of time to go through primary care and if they don’t feel they can meet your medication needs, they can refer you on. Plus, then you have someone to call next time you think you have strep throat.”
Thirty-something client for whom one antidepressant did not work. “Hi Katie. I know you’ve been looking for a psychiatrist after the medication prescribed by your PCP didn’t work for you. Sometimes it’s hard to find someone in network. Have you considered going back to your PCP to tell them about your experiences on the first medication? I would suggest that you make an appointment and perhaps ask the scheduler if you can have some more time, as these discussions sometimes take more time than a typical 20-minute spot. Let them know what you experienced and ask them what their next suggestion would be, given that your symptoms are still so severe. I am aware that many PCPs will go through many more medication trials before referring to a specialist.”
Client with health anxiety/illness anxiety disorder. “Hi Katie - I know you so want to be responsible with your healthcare and to that end, you’ve worked with multiple specialists over the last few years. I am concerned that you don’t have a single point of contact, coordinating these efforts to work up your symptoms. I’m worried that there may either be gaps in your workup or redundancies that are costing you a lot of money. I find I make the most progress with clients who have a dedicated primary care physician who can be our “reality checker” about symptoms.”
Client with insomnia, interested in CBT for insomnia (CBTi). “Hi Katie - CBT for insomnia is contraindicated with certain medical conditions, particularly sleep apnea. Before we begin, I think it’s important that we get your doctor’s sign-off that they feel comfortable with us proceeding with CBTi and that they don’t think you have any medical issues that better explain your sleep difficulties.”
Confident, directive, with good boundaries
We are not medical practitioners but we are clinicians trained to spot possible warning signs of disease outside of what’s defined in the DSM. No we can’t diagnose or treat hypothyroidism, but we can ask our clients to consult with their doctors on possible medical causes for depressive symptoms so that we don’t run up thousands of dollars of therapy bills when what a client really needed was thyroid medicine. Our clients and our physician-colleagues deserve our boundaries around dispensing medical advice and our support in advocating for our clients’ physical health.
There are so many things I know I need to improve on as a professional, but this is one area I feel pretty confident in, so if you’re a client or a mental health clinician who needs help navigating this sometimes dicey intersection, I’m happy to help!
Oh and I hope to be able to actually develop that algorithm flow chart on how to do this, someday….