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Primary Care Physician Perceptions on Caring for Complex Patients with Medical and Mental Illness

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ABSTRACT

BACKGROUND

Mental illness is common and associated with poor outcomes for co-occurring medical illness. Since primary care physicians manage the treatment of complex patients with both mental and medical illnesses, their perspectives on the care of these patients is vital to improving clinical outcomes.

OBJECTIVE

To examine physician perceptions of patient, physician and system factors that affect the care of complex patients with mental and medical illness.

DESIGN

Inductive, participatory, team-based qualitative analysis of transcripts of in-depth semi-structured interviews.

PARTICIPANTS

Fifteen internal medicine physicians from two university primary care clinics and three community health clinics.

RESULTS

Participant characteristics were balanced in terms of years in practice, practice site, and gender. Physicians identified contributing factors to the complexity of patient care within the domains of patient, physician and system factors. Physicians identified 1) type of mental illness, 2) acuity of mental illness, and 3) communication styles of individual patients as the principal patient characteristics that affected care. Physicians expressed concern regarding their own lack of medical knowledge, clinical experience, and communication skills in treating mental illness. Further, they discussed tensions between professionalism and emotional responses to patients. Participants expressed great frustration with the healthcare system centered on: 1) lack of mental health resources, 2) fragmentation of care, 3) clinic procedures, and 4) the national healthcare system.

CONCLUSIONS

Physicians in this study made a compelling case for increased training in the treatment of mental illness and improvements in the delivery of mental health care. Participants expressed a strong desire for increased integration of care through collaboration between primary care providers and mental health specialists. This approach could improve both comfort in treating mental illness and the delivery of care for complex patients.

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ACKNOWLEDGMENTS

This study was funded by the University of Colorado Division of General Internal Medicine Small Grants program. Danielle Loeb, MD received salary support through the University of Colorado Primary Care Research Fellowship funded by Health Resources and Services Administration. Ingrid Binswanger, MD, MPH was supported by the Robert Wood Johnson Physician Faculty Scholars Program, by the National Institute on Drug Abuse (1R03DA029448, 1R21DA031041-01). The content is solely the responsibility of the authors and does not necessarily represent the official views of any of the funders.

Prior Presentations

The findings from this study were presented at the Society of General Internal Medicine Annual Meeting in Phoenix, AZ in 2011.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Author information

Authors and Affiliations

  1. Division of General Internal Medicine, Department of Medicine, University of Colorado, Academic Office 1; Mailstop B180; 12631 East 17th Ave., Aurora, CO, 80045, USA

    Danielle F. Loeb MD & Ingrid A. Binswanger MD, MPH

  2. Kaiser Permanente Institute for Health Research, Aurora, CO, USA

    Elizabeth A. Bayliss MD, MSPH

  3. Department of Family Medicine, University of Colorado, Aurora, CO, USA

    Elizabeth A. Bayliss MD, MSPH & Frank V. deGruy MD, MSFM

  4. Division of Substance Dependence, University of Colorado, Aurora, CO, USA

    Ingrid A. Binswanger MD, MPH

  5. Denver Health and Hospital Authority, Denver, CO, USA

    Ingrid A. Binswanger MD, MPH

  6. Department of Communication, University of Colorado, Boulder, CO, USA

    Carey Candrian PhD

Authors
  1. Danielle F. Loeb MD
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  2. Elizabeth A. Bayliss MD, MSPH
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  3. Ingrid A. Binswanger MD, MPH
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  4. Carey Candrian PhD
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  5. Frank V. deGruy MD, MSFM
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Corresponding author

Correspondence to Danielle F. Loeb MD.

Appendix. Examples of Open-Ended Questions Regarding the Treatment of Mental Illness Used During Interviews

Appendix. Examples of Open-Ended Questions Regarding the Treatment of Mental Illness Used During Interviews

Working definition of complexity: A complex patient is defined as a person with two or more chronic conditions where each condition may influence the care of the other condition. This patient may have other factors such as age, race, gender and psychosocial issues that also influence the morbidity associated with their chronic conditions.

  1. 1.

    I would now like you to consider the interaction of mental illness and chronic medical illness in patients. Could you share with me your general impression of this interaction?

  2. 2.

    We are specifically interested in exploring the ways in which mental illness affects your management of medical illness. Could you share with me your impression of the impact of a mental illness in patients that are medically complex? Could you share with me any specific experiences you have had managing medically complex patients with mental illness?

  3. 3.

    Please refer to the patient charts you brought with you today. What made you pick these three charts?

  4. 4.

    If they have a mental illness diagnosis, can you talk a bit about whether their mental illness affects their care? Do you feel their mental illness affects their medical illnesses?

  5. 5.

    What do you find most enjoyable/rewarding in the care of these patients?

  6. 6.

    What do you find most frustrating / challenging in the care of these patients?

  7. 7.

    How have you been trained to care for patients with mental illness? Was there a specific activity in medical school or residency where you learned to treat patients with mental illness?) Were there specific training experiences after residency?

  8. 8.

    Is there any training that you feel would have better prepared you to treat complex patients, especially those with mental illness diagnoses?

  9. 9.

    What do you feel like you would need to improve your care of the complex patients in your clinic?

  10. 10.

    Is there anything on a system level in you clinic or beyond your clinic that would support you in the care of complex patients?

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Loeb, D.F., Bayliss, E.A., Binswanger, I.A. et al. Primary Care Physician Perceptions on Caring for Complex Patients with Medical and Mental Illness. J GEN INTERN MED 27, 945–952 (2012). https://doi.org/10.1007/s11606-012-2005-9

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  • DOI: https://doi.org/10.1007/s11606-012-2005-9

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