Addressing the mental health care gap in primary care

In the November 2019 issue of Contemporary Pediatrics, Dr. Mollika Sajady and her co-authors describe their institution’s approach to addressing the gap in mental health training for primary care pediatricians. The article quotes that mental health concerns affect 1 in 5 children in the United States and that more than 50% of recently graduated general pediatricians report a need for more mental health training. The authors’ institution, the University of Minnesota in Minneapolis, has received federal funding to establish collaborative office rounds (COR), which is 1 of 10 such programs in the nation. The authors provide a detailed account of the COR process; its benefits to the attendees; and how they have addressed some of the limitations of COR.

How did we get here in the first place?

Why is there a gap in the mental health training of general pediatricians? This is a question that brings about a wide spectrum of opinions and likely just as many emotions from clinicians. Although there is no single answer to this question, as evidenced by the article’s references, the lack of appropriate training in mental health remains an issue in the training of pediatricians. The problem seems to be self-compounding, as prior generations of pediatricians had gaps in training, the incoming generations are less likely to learn from these more experienced colleagues and mentors about mental health screening and care.

Along with the deficiencies in education and training, financial and reimbursement barriers also prevent general pediatricians from closing the gaps in their training. Historically, insurance reimbursement for addressing mental health concerns has been poor. Referrals to mental health experts may be met with long wait times for appointments and/or significant out-of-pocket expenses for the family. With little financial incentive for primary care providers to spend time increasing their mental health training, the gaps from the traditional medical education continue to grow.

Addressing the problem

The University of Minnesota has sought to address this issue in a way that directly targets medical trainees and practicing pediatricians. They offer their depth of expertise in mental health in a way easily accessible to community clinicians. Improving the confidence of general pediatricians to address mental health concerns among their patients is a major step in appropriately addressing the needs of patients. Simply having met an expert in person, or even by video conference, makes the expert seem more approachable, and the generalist more likely to reach out when facing a difficult situation.

The COR model is just one example of how clinicians are taking the steering wheel when it comes to closing the gaps in mental health education. Didactic and clinical training in mental health for student physicians, nurses, physician assistants, and other healthcare professionals needs to be improved upon so that future generations of learners will have appropriately trained mentors.

Mental health training beyond the primary care provider

The aspect of improving the training for all clinical students within their required didactic years is important. Some will practice in primary care and some will find their way into a specialty role. Although primary care providers will likely remain the first step in screening for and addressing mental health concerns in pediatric patients, one must not exclude the need for specialists to also feel confident in their ability to screen for mental health concerns. A young patient with type 1 diabetes may have more encounters with their endocrinologist than their pediatrician; the same may be true for any chronic disorder that requires ongoing specialty care including asthma, sickle cell disease, inflammatory bowel disease, etc.

As pediatricians, we have the ability to set in motion a healthy and productive way for our patients to understand and manage their mental health concerns. Appropriate, timely, and ongoing training for pediatricians is of the utmost importance in promoting clinician confidence in mental health and is essential to the management of all pediatric patients. A huge kudos goes out to the University of Minnesota for leading in the effort to address these issues.

Susan Kirk, Member-at-Large and Board Member of SPAP, received her Bachelor of Science in Biological Engineering at Mississippi State University and Master of Physician Assistant Studies at the University of Kentucky. She has practiced in pediatric hematology/oncology for her entire PA career, currently at Texas Children's Hematology Center and Baylor College of Medicine. She enjoys sharing her passion for hematology with the next generation of medical providers.