The best and worst thing about working with students is that they’re always asking uncomfortable questions about why things are the way they are. Early in my academic career, I had a student who wanted to know why some patients in my clinic had an easy time getting their diabetes under control, while others struggled mightily. Were some of our doctors just worse than others?
We decided to conduct a simple study. After getting the appropriate permissions from our institution and our patients, we identified patients who’d made sustained improvements and others who struggled. The student conducted interviews with both groups to see if we could understand what was going on. Invariably, those that struggled had something going on in their personal life that made it hard for them to focus on eating the right foods and taking their medicines. One had been going through a difficult divorce; several others were struggling with loneliness and social isolation. While we didn’t formally assess this, I suspect that most if not all of them also faced depression or some other mental health condition.
If patients’ emotional and psychological health had such a profound effect on their physical health, why weren’t we doing more to address them?
I had expected the student would find that social challenges contributed to poor health. I was shocked, however, that such challenges appeared to account for nearly all the differences between the two groups. If patients’ emotional and psychological health had such a profound effect on their physical health, why weren’t we doing more to address them?
Yes, our clinic employed social workers, but we tended to involve them in times of crisis, like when a patient was suicidal or so out of control with their drinking that they needed rehab. I was spending a lot of time trying to make sure my patients followed through on cancer screenings—expensive tests like colonoscopies that have been shown to have a real, if modest, impact on picking up cancers early so we can intervene before they spread. It would be hubris to think that we could impact the broader societal forces, like racism and income inequality, that cause higher rates of illness in some groups than others. But surely we could do more to proactively support our patients of all social strata whose emotional and psychological struggles were their greatest barrier to good health.
Since I started working on Firefly Health, I’ve heard a number of investors and entrepreneurs say something to the affect of “but behavioral health is a black box.” Their implication is that we just don’t know what works for conditions like depression, anxiety, and substance use disorder (SUD), which are at epidemic proportions and so important to employers, who purchase health care for about half the country. I’m not sure why this belief is widespread, but it just isn’t true. Pioneered by Dr. Jürgen Unützer and the AIMS Center at the University of Washington, there’s extensive scientific evidence that we can improve symptoms of depression by as much as 50% within a year without people even having to go for a separate appointment to a psychiatrist. Dr. Unützer called this the Collaborative Care Model (CCM). If he had developed a pill that worked this well, it’d be everywhere.
...we can improve symptoms of depression by as much as 50% within a year without people even having to go for a separate appointment to a psychiatrist.
At Firefly, we’ve built a technology platform and team-based model to scale a proactive, personalized, evidence-based approach to supporting our patients’ emotional and psychological health. Designed after the CCM, each Firefly Care Team has a behavioral health specialist (BHS - typically a licensed clinical social worker) and a psychiatrist. The psychiatrist supervises the BHS, reviewing all cases, helping to make certain we have the correct diagnosis and making recommendations about treatment.
We screen all of our patients regularly for depression, anxiety and SUD. For anyone who screens positive or reports that they’re struggling, we set up a same-day video visit. That visit sets in motion scientifically-validated protocols for ongoing assessment and support, including the best medications when indicated, therapy, and regular check-ins.
An advanced approach to addressing mental health challenges is necessary for supporting our patients’ whole health. But it’s insufficient without also addressing the inter-related behaviors—particularly diet, sleep and exercise—that drive health outcomes from chronic conditions and can be part of vicious or virtuous health-related cycles. Here too, we’ve developed a new approach that leverages teamwork and smart technology.
As part of our annual whole health assessments, our MDs and NPs work with our patients to identify personalized goals for behavior change. We then have a warm hand-off to our health guides, who work with our patients to identify a set of tasks and a communication and support plan for making the behavior changes. These care plans often include trials of best-in-class digital tools. Our technology is built to help us learn over time which tools and communication patterns work for which groups of people so we can continuously improve the support we provide.
For me, building a different kind of system that integrates advanced behavioral health approaches into medical care has been the best therapy for that helplessness.
Practicing medicine in the traditional model, with minimal support for behavioral health, can feel like trying to hammer in a nail with a watermelon. Being confronted by suffering without the tools to mitigate it is one of the hardest experiences for a healer. By the end of the student’s project, they and I were feeling helpless and overwhelmed; a feeling that was compounded multiple times over the ensuing years as I continued to encounter patients I couldn’t sufficiently care for.
For me, building a different kind of system that integrates advanced behavioral health approaches into medical care has been the best therapy for that helplessness. There’s no health without emotional and psychological health. The delivery systems of the future will be built on that premise.
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