Expert calls for GP psychiatrist sub-specialty

Doug Hendrie

1/05/2019 2:59:38 PM

A prominent GP and researcher has suggested the sub-specialty to help provide better treatment to patients with mental health conditions.

Assoc Prof Louise Stone
Associate Professor Louise Stone is calling for a new GP sub-specialty in mental health.

Mental health is now the single most common reason patients see their GP, and the health issue that causes GPs most concern for their patients’ future.
GP and Australian National University (ANU) Associate Professor Louise Stone recently raised the idea of a GP psychiatry sub-specialty as a way to treat ‘the patients lost in the middle’ – those who are too well for acute mental health and too sick for primary health networks and headspace.

Associate Professor Stone told newsGP the patients seen by GPs are often not seen by other mental health professionals.
‘The patients we see are often those who don’t go to psychologists or psychiatrists, particularly those who can’t afford long-term care and who have a history of long-term trauma. The system doesn’t offer public care for those patients,’ she said.
‘We see a lot of patients with mental health problems that we wouldn’t call disorders. Grief, breaking bad news, workplace bullying and harassment, patients coping with the birth of a child with a disability, the transition to palliative care, becoming a carer and struggling with the emotional impact of it.
‘Those patients belong in our space as GPs.’
Associate Professor Stone believes a possible structure for GP psychiatry might be to add a third level of accredited training to the existing two levels set by the General Practice Mental Health Standards Collaboration (GPMHSC).
‘You would be able to demonstrate to the [GPMHSC] that you have the experience, not only the qualifications,’ she said.
According to Associate Professor Stone, however, better funding for GP mental health would have to accompany the sub-specialty.
‘It’s $2 a minute to see a suicidal patient, and $6 a minute for six-minute medicine. You take a cut when you see a longer patient,’ she said.
‘I love the work, but I’d go broke if I did it all day.’
Associate Professor Stone said that, as generalists, GPs are well placed to look after these patients.
‘GP psychiatry would be about finding GPs who have made this their interest within general practice,’ she said.
‘We take the patients everyone else rejects. We talk about stepped care, but we’re the closet under the stairs.
‘My vision of it is not about becoming a psychiatrist, but about doing the work we already do in general practice and going deeper in what we actually we do.’
Associate Professor Stone outlined a possible structure for a GP psychiatry sub-specialty
‘If we’re able to recognise this, we might be able to get VMO [visiting medical officer] status in rural communities so we can admit patients,’ she said.
‘It’s about time we had an MBS item for an extra level of care for 50 minutes for trauma or suicidality. At the moment, I do ridiculous amounts of pro bono work because I can’t charge adolescents sleeping in cars. You just can’t.
‘Because of that, we need to make sure GPs who do this work don’t burn out. Their income is so much lower than if they only did procedural work, and the emotional impact is high.
‘Mental health in general practice is really different. I spent my first 10 years as the only female GP within three hours, so I was flooded with trauma. I delivered lots of babies to women who had been sexually assaulted. The work finds you.
‘One of the things we do that psychologists and psychiatrists don’t have the chance to is get people really early, before they form their ideas [about their condition]. They don’t know they have depression or anxiety. They just know they feel wrong.
‘It’s up to us to shape the story, to give people ideas to hold on to and to help them seek care.
‘You might have a patient coming in with chest pain, irritable bowel syndrome and intergenerational trauma, and you’re trying to give them a sense of where their psychological history fits, and then do matchmaking for them to find the right psychologist or psychiatrist to take them forwards.’
Associate Professor Stone said the current primary care mental health system – such as mental health care plans – might be a good first step for many patients, but leaves the complex and challenging issues untouched.
‘Mental health care is now very commodified and is seen much more procedurally,’ she said.
‘You make a diagnosis, follow the protocol, give an aliquot of care, the patient gets better. But that just doesn’t work in my world. It just doesn’t work.
‘If I take a patient with intergenerational trauma, somatisation, sexual abuse and four chronic diseases, calling it depression and giving cognitive behavioural therapy [CBT], it’s not what it is. A little bit of CBT is a drop in the ocean.
‘It doesn’t touch childhood trauma, which affects one in four women and one in six men, and which we know does awful things to a person’s sense of self. What we need is trauma-informed care and a longstanding relationship with someone who treats them with respect.
‘For those who are really unwell, I’d prefer them to be seeing a psychologist or psychiatrist every fortnight over years. But we’ve chosen not to fund that, and so instead I’m the surrogate.’

mental health stepped care sub-specialty

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Dr Julia Driscoll   2/05/2019 7:31:08 AM

Oh yes!! I can relate most strongly to that! My health has impeded me from doing procedural work - even an afternoon of it to have a break.
We GPs are ideally placed to fill the gap and provide truly wholistic care to a wide range of patients who can not afford psychological or psychiatric care . I earn on a good day in general practice 80 gross an hour. Then I should pay tax, superannuation, holiday pay and sick pay. I can only work 31/2 days a week. Medicare does not pay well.. But I am still an idealist and I like to think I make a difference in this world. . I have been working as a general practitioner for nigh on 30 years and am raising three children. It is well that I feel it is a true vocation to be a GP - cause if it weren’t I would find another job! Bring on the sub specialty!

Aline Smith   2/05/2019 7:38:00 AM

Louise, great article. You are right you can't charge adolescents sleeping homeless but you can charge the worried well, IE the anxiety ridden people who also come to GPs a lot. My private patients have been subsidising my poor patients since 1992 and the gap payment gets bigger every year
GP s with these higher credentials should be able to claim more Focus psychology items than just 10 as per psychologist with your rationale . Recently I got myself some extra training for Complex trauma as I too have been treating many people for this especially since the RC on Child sexual abuse ....GPS not only have to help patients make sense of their mental distress but also their physical symptoms associated with this. Amazingly when I tried to get this training veted as a FPS training as CPD I had to see how the training fitted into CBT and IPT !so you are right , it appears these seem to be two therapy framework recognized, how totally frustrating.
I am still awaiting the outcome

Dr Aletia Johnson   2/05/2019 9:01:50 AM

What a fabulous idea! I’m a female GP who specialises in mental health, chronic pain and trauma. I’ve got 15 years experience, level 2 mental health training, a degree in psychology and yet, the registrars at my practice earn twice what I do, because long consults and mental health work aren’t properly funded. It’s all well and good to have level 2 funding, but you can’t even use it if the patient needs a psychologist as well. I’m sick of the irony - the more I help people, the more complicated the patient, the less I get paid.

Louise Stone   2/05/2019 9:44:20 AM

Thanks for the comments everyone. I do want to say that I value the work of generalists: it is the core of who we are. And I am not suggesting we create an elite tribe of superspecialist GPs. But we have GP anaesthetists, and GP obstetricians and we do have many GPs who are expert in this space who need support. I worry about many young women GPs who are flooded with responsibility, but have little access to support or training. And it shouldn't only be GPs with diplomas or extra degrees: passion, experience and expertise matter

I've written a longer paper on this, if anyone is interested, which can be found here

Dr Naomi Rutten   2/05/2019 10:52:40 AM

Couldn’t agree more. Have just started my own GP Mental Health Clinic for this exact reason.

Margaret Swenson   2/05/2019 12:14:24 PM

Agreed ! As a rural GP who sees a lot and has recently had a Medicare audit ... with the person wondering why I do soooo many 2713 and 36/44 ....

Susi Fox   2/05/2019 1:09:59 PM

Love this idea Louise! Please get it going! GPs do such important but poorly renumerated work in the mental health space. Would be great to be adequately paid and recognised for this work.

Cherelle Fitzclarence   2/05/2019 5:35:30 PM

Well said Louise.

Dr Brendan John McPhillips   2/05/2019 5:37:32 PM

This is an excellent and timely article.
I am a GP who specialises in caring for patients who have suffered long-term trauma, mostly sustained in childhood either through neglect or abuse or both, for which, as Professor Stone has rightly commented, 6-10 sessions of CBT is virtually useless.
I have a Diploma in Adult Psychotherapy, a Masters in Medicine in Psychotherapy, and am currently enrolled in a PhD looking at what helps in longer-term therapy. And yet, although doing this work for 25 years, not doing the shorter-term work of the FPS, I can only use Item 44, and must justify myself to Medicare every 5-10 years for the work I do because I fall outside the parameters of the usual use of this item number.
A new Item number for 50 minutes dedicated to work with these deeply-suffering patients would be very welcome.

Christopher D Hogan   2/05/2019 11:36:22 PM

This is not the first time this has been tried. I was a member of the RACGP- RANZCP Victoria liaison committee, subsequently appointed to the course committee for the Graduate Diploma in General Practice Psychiatry of Melbourne & Monash Universities
G Blashki, McCall L, Hogan C et al. A Graduate certificate & Master in General Practice Psychiatry by Distance Education 1998-2001. Aust Fam Phys 2002; 31(4): 394-398

Christopher D Hogan   2/05/2019 11:46:50 PM

This is not the first time this was tried.
I was a member RACGP- RANZCP Victoria liaison committee in 1995, subsequently appointed to the course committee for the Graduate Diploma in General Practice Psychiatry of Melbourne & Monash Universities. It became a Masters Degree & then after a few years, it floundered from lack of interest. There was no one else interested.
G Blashki, McCall L, Hogan C et al. A Graduate certificate & Master in General Practice Psychiatry by Distance Education 1998-2001. Aust Fam Phys 2002; 31(4): 394-398
Hopefully our efforts will lead the way to a better solution.

Judith Ellis   3/05/2019 8:14:59 AM

Totally agree with everything in this article and the comments. Especially this "What we need is trauma-informed care and a longstanding relationship with someone who treats them with respect." The effects of childhood trauma with chronic mental scars that usually also present as physical and functional illnesses are best addressed in GP. Enlisting other support with local trauma informed psychologists, physios, dietitians etc is essential too. So many patients falling outside what our systems limit access to and GPs offer ongoing, under renumerated collaborative care that is containing and preventative of progression to hospital admission, suicides and further intergenerational trauma.

Amabel Harding   3/05/2019 6:28:44 PM

Please let me know if it eventuates, would be interested

Bronwen Howson   6/05/2019 11:22:52 AM

An excellent article. Yes I agree and would also be interested in doing such training as much of my work rests in this area. Thanks.

Murray Schofield   6/05/2019 5:02:24 PM

When can we get cracking and kick off a course 2020? Maybe the RDA / AMA/RANZCP collaborative with the college particularly with funding for rural generalists being a hot topic.
Get an Engineer to project manage it an it will up and running by next year 2nd semester.
Woohoo Great initiate....when can we enrol.

Dr Darcie Nottage   24/04/2023 4:59:52 PM

Any update on this 4 years later? Rural Generalism now has training positions for 'GP Psychiatry' but as far as I'm aware it doesn't give access to any specialist item numbers, or even recognise the extra training in terms of having authority to review ITOs.

I'm a mental health inclined rural GP who expects to practice for another 30 years, I should be exactly the target for this extra training but I can't see that it will be worth disrupting my family life or my patient care as I would have to move away from my community to pursue this qualification for a year or more.