7 minute read

From the fifth floor window of the resident lounge, I could see the downtown Chicago skyline in the distance from Hinsdale Hospital. The Hinsdale Family Medicine Residency building was across the street from the hospital I would call home for the next 3 years, connected by an underground tunnel that came in handy as we scurried back and forth from the hospital to the office in the Chicago-land winters and heavy snow. But today it was summertime, June 2007.

Fresh out of medical school at Southern Illinois University, I arrived at the residency building, a former church converted into a medical office. The building retained some stained glass windows, a nod to its past, and the familiar scent that only mature church buildings possess.

In academic medicine, July marks the beginning of training for resident physicians, often referred to as “not the time to need emergent medical care” because of the influx of new doctors. Residency orientation typically begins in mid-late June so that on July 1, the next group of learners hits the ground running. I still recall the dread as my classmate James glanced at the on-call schedule and teased, “Ooh, Jen. You’re first up! You got Internal Medicine call July 1!” Yikes.

The first week of residency was a blur of nerves and anticipation. One memory that always stood out from that first week as a “real doctor” was our Advanced Cardiac Life Support (ACLS) class.

Developed by the American Heart Association, ACLS is a standardized framework for healthcare professionals to follow during cardiopulmonary arrests or other cardiovascular emergencies. So getting this training in the last days of June, right before I was starting in the “real world” on July 1, was a big, important deal.

ACLS training equips you to spring into action when there is a “code.” As an intern doctor, you could be enjoying a few moments of peace eating breakfast with your fellow residents after a long night on-call, when suddenly over the hospital intercom a loud voice announces, “ Code Blue: ICU. Code Blue: ICU.” Everyone drops what they are doing and rushes to the designated room, leaving behind their breakfast and much-needed coffee.

While I no longer hear “code blue” over the intercom daily, I witness a different “emergency” in the primary care setting

As Samuel Shem advises in his satirical classic, The House of God, “At a cardiac arrest, the first procedure is to take your own pulse”, reminding us to remain calm in an emergency. Fundamental to the ACLS training is the importance of clear, effective communication among team members so that accurate information is shared during high pressure situations. The team works together, with clearly defined roles, collaboratively analyzing complex situations.

My days of running codes are long behind me. I’m now in the “middle aged” era of my time as a family doc, spending my days in the office rather than the hospital. While I no longer hear “code blue” over the intercom daily, I witness a different “emergency” in the primary care setting, one that is so widespread and perhaps less dramatic than a cardiac arrest, that it can be overlooked or accepted as “just the way it is.”

 What I’m talking about is the crisis of unmet behavioral health needs. Primary care delivers most behavioral health and mental health care in this country. Most antidepressants are prescribed by primary care physicians, not psychiatrists, and most U.S. counties have severe shortages of behavioral health clinicians and services.

I think one of the silver linings coming out of the Covid pandemic has been a shift in our collective comfort level in talking about our mental health as HEALTH. Maybe it’s because we all went through that shared trauma together- none of us knew how this would all turn out in early 2020. The shared trauma of the pandemic, with 1.2 million American lives lost, including 115,000 healthcare workers, has led to more open conversations about mental health, a positive step forward.

The situation for children is even more dire. In Oct. 2021, the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and Children’s Hospital Association declared a national emergency in child and adolescent mental health and this need remains as urgent today in 2024.

In response, recommendations were made to implement school-based mental health programs and increase capacity in primary care through integration, something many of us had been doing well before the pandemic.

Other approaches included trying to re-tool, coach-up primary care providers to do more psychiatric care to solve the behavioral healthcare shortage. While I fully support on-going education and have been the recipient of many excellent training programs that grew my comfort in treating mental health disorders, asking the busy PCP to “do more” and be “an army of one” may not be the healthiest, most sustainable approach either. The American Medical Association (AMA) reports up to 62% of physicians suffer from burnout, and since the pandemic, an estimated 71,000 physicians have left the workforce.

That’s what it feels like to be a PCP trying to help someone with a behavioral health concern without an integrated care team. Without integrated team or specialty behavioral healthcare, we may know of effective approaches, but many treatments are out of reach due to barriers such as cost, distance, and lack of in-network providers.

As busy PCPs, it can feel like we’ve rushed to a “behavioral health code” only to find that no one else is there. We can’t manage everything alone; it’s unreasonable to expect one person, even “the Doctor,” to handle all aspects of care solo.

Maybe, instead, we need to look at this crisis through a “Yes, and…” lens, with numerous bold and creative approaches to redesign our siloed health systems. We need our healthcare providers and our communities to join a rally-cry and demand the Medical Establishment help us respond to the “mental health crisis” as a TEAM, rather than as solo, isolated clinicians.

Team-based care works. Treating the body without treating the mind won’t work as well as whole person care.

Our foundational medical training (ACLS, Day 1 training as newbie-docs) was on to something that still serves us today: It takes a team with clearly defined roles to address a crisis. We need to get out of our own way in thinking the “solution” to the mental health crisis is somehow so complex that we don’t know where to start. We know where to start. We go back to basics and pull together a team of people and work together to save the life of the person in front of us.

 We need to demand that our health systems and insurance companies equip us with the tools and teammates necessary so we’re not left figuring it out on our own. Connecting with someone who is truly suffering and helping them see a path forward can be just as life-saving as delivering a shock to restart a heart.

Integrated Care service delivery models are out there, and there are amazing people doing this work every day. We just need this approach to reach more clinicians and patients, when and where they need it. I envision a future where Integrated Care is just as foundational to our Day 1 medical training as ACLS, so the next generation of medical providers instinctively think of a team-based framework for behavioral health as they do CPR for a heart attack.

This July, as the next generation of doctors walk in the door and we greet them with “Here’s what you’re gonna need to know when the S*** hits the fan, because it definitely will”, let’s simplify the approach to behavioral health needs.

Team-based care works. Treating the body without treating the mind won’t work as well as whole person care. Going it alone won’t work as well as being a part of a team. So let’s go get some new teammates and get to work.