I recently had the opportunity to attend the Twenty-fourth Annual Rosalynn Carter Symposium on Mental Health Policy in Atlanta, Georgia. At this remarkable meeting 200+ persons from across the US convened to revisit the progress that we have made as a country since Jane Knitzer’s seminal Unclaimed Children report over a quarter-century ago. This meeting highlighted presentations and discussions based on recently completed research conducted by Janice Cooper, Jane Knitzer, and their colleagues at Columbia University, Unclaimed Children Revisited: The Status of Children’s Mental Health Policy in the US.
According to Cooper and colleagues’ findings, we have witnessed meaningful shifts in the culture of care in the last 25 years, often in specific regions and as a function of strong state leadership. However, more in-depth analysis revealed that “changes, while promising, are often severely limited in scope and shallow in depth due to lack of concerted strategic plans.”
I agree. It is ironic, even tragic, that NIH has spent over 2 billion dollars on child mental health-related research since 1990, but getting this information and new methods out into our communities and to our families has hardly progressed whatsoever. We have made remarkable strides in terms of developing better diagnostic tools and more effective treatments, but as a country we have not put into place the necessary mechanisms that take correct principles and proven programs to their ultimate destination — families. And it truly is not “rocket science!” Successful examples exist that indicate that the necessary steps are fairly straightforward. When a discovery is made or a new finding is developed, four steps are needed to take it to market, at least in the child health and human services arena:
- Identifying and validating successful programs with the key stakeholder groups; a discovery won’t last long if it is repudiated by other scientists, or is felt to be unacceptable, unaffordable, infeasible, or unsustainable within larger communities.
- Adapting them for wider dissemination so that they fit the cultural needs of new communities, with those communities’ buy-in. Rarely is an innovation fully ready for prime time right out of the university investigators’ laboratory. Lots of input, adaptation, and modifications are often needed, where the researcher learns what the community really needs and wants…which may not be exactly what the researcher did.
- Disseminating the programs with the leverage of those communities, and assisting those communities to bring additional funding sources to the table as needed; and
- Empowering those communities to continue delivering the latest, scientifically updated versions of the programs through some kind of central, non-profit, publicly oriented support function.
These 4 steps often take years, and without careful assistance, they result in what the Institute of Medicine concludes is an 18-year science-to-service translational gap in putting science to work for families. So the likelihood of any child or youth getting state-of-art, up-to-date care for mental health problems is small, unless the family travels long distance to one of the 4-5 universities doing the cutting edge research in that area.
However, in our experience at the REACH Institute, these four steps, done strategically and systematically, can be completed in as little as 3 years, when all the key stakeholders are quickly brought together, essentially forming a science to service dissemination pipeline.
Why the delays? When I was at NIMH from 1990-2000, where I served as the Associate Director of Child & Adolescent Research, we often saw that the first two steps (identification and adaptation) would take years, often because most of our scientists naturally do what they were hired to do, and in fact do best: test and compete various programs in the market place of ideas, and then publish these findings in scientific journals. As scientists we tend to debate for years in the pages of our journals about best methods, while families and community health providers remain confused about best practices. In fact, while I was at NIMH, we only hosted one NIH- sponsored Consensus Conference during the entire decade while I was there…for ADHD in 1998. So how are competing professional scientific discplines going to reach consensus on thorny issues like teen depression, or use of medications vs. psychotherapies? And even if consensus can be reached with scientists and consumer stakeholders, who is there for the second step? — to adapt the beta-versions (university lab prototypes) so that they are readied for distribution across the science-to-service pipeline (if it existed). Adapting the interventions to “the real world” and then helping others apply them, was not then, and is not now, a common function of universities.
While still at NIMH, Lisbet Shore’s book “Common Purpose” had a great impact on me. She described the case stories of successful national dissemination programs, and detailed the factors associated with successful disseminaton. One common factor was that successful programs usually had a hands-on, national training and technical assistance center that systematically helped new sites learn the program, adapt it to their communities, and then provided ongoing support and evaluation.
This is why the REACH Institute was formed in 2006. Because the ultimate success of any program depends upon whether it actually “reaches” and helps children and families, key leaders from NAMI, CHADD, MHA, and FFCMH, serve on REACH’s Board to guide this process. In addition, because of the somewhat fractious nature of our field historically, as well as concerns about commercial interests, we established REACH with a great deal of interdisciplinary input, and obtained IRS approval as a 501c3 non-profit. Its 501c3 status allows generous individuals invested in child mental health system reforms to make non-profit donations to bring the latest methods to their local communities’ health/mental health providers. In addition, my own time on behalf of REACH is donated pro-bono, in order to avoid any misinterpretations about personal financial gain.
Now that REACH is up and going, I believe it has something to offer all of us interested in transforming children’ mental health and reaching all children across the country. Speaking on behalf of REACH, we are are eager to partner with individuals and organizations at local, state and national levels, and across the range of provider disciplines and consumer voices that need to be involved to solve our problems. We are eager to make all of our tools and programs available to anyone committed to transforming children’s mental health across the country.
A brief one-pager describing some of REACH’s current programs is available at the link www.TheReachInstitute.org/documents/REACHintro.pdf. Also, please drop me an email note if you have ideas on programs and partnerships that we might follow up on together. Or to get a more extended view, please go the homepage and browse to your heart’s content, www.TheReachInstitute.org.
Happy Holidays! peter jensen
If you are interested other comments on these issues, go to blog catchservices.wordpress.com and add your comments about how change might be accomplished.
18 Comments
Pleased to see the start of this blog. I am familiar with the outstanding work REACH and its founder, Dr. Jensen, are doing to shorten the time it takes to get science off the shelf and into the hands of caregivers for American youth with behavioral and emotional challenges. Keep up the good work for America’s youth!
It seems to me the steps are backward and not revolutionary enough. They assume that things should start with the ivory-tower lab and then be disseminated through the 4 steps. That’s a good way to disseminate physical/chemical technology (stack scrubbers, atom splitting, microchips, semiconductors, new drugs, new imaging techniques, etc.), but i question whether it’s the right path for people services.
Why not start with the community and identify the problems that need intervention, then ask the ivory tower for bids to design and test interventions to address those needs? The community would be informed of progress and could be poised to implement as soon as the evidence is in. This approach could also facilitate recruitment to studies, the most critical obstacle to timely research completion. It looks like win-win to me.
Of course, there would still need to be the ivory-tower basic science to generate the new knowledge without immediate obvious application, but on which future interventions could be based.
I absolutely agree with Gene Arnold’s post. In fact, Kimberly Hoagwood and Barbara Burns made the same point in a model they proposed, where initial treatments have to be developed in dialogue with the community. While the REACH Institute’s initial post on this topic does not make Dr. Arnold’s point explicitly, it is a part of the REACH dissemination model, that assumes that there is an initial dialogue with consumers (meaning clinicians as well as families) to make sure that what is offered and adapted for dissemination does in fact meet consumers’ needs. Oftentimes as researchers, we develop programs in isolation, without any market research, only to find out later that our interventions are not palatable, acceptable, or feasible in the real world. Businesses that try to operate that way do not stay in business for long….
peter jensen
I think the most effective way to get evidenced based knowledge to be used in the cimmunity is through the use of algorthms like the Star D depression one. That wasy families and practitioners have pathways to treatment with likely precentages of response at each step to look at.
I am truly so encouraged to see the work of REACH. I am confident that together with REACH and Families/Communities we can finally get the mental health care that we so desparetly need for our children.
Before we can disseminate evidence based treatments we need to realize that the professionals we expect to implement these treatments are professionals, that is they do it for money, this is how they make a living, each practice is a small business. To expect people to change what they do with no incentives is just not practical. We have to look at what we want them to do differently, determine how they will be reimbursed, and work from there.
For example, I could fill my schedule every day with individual child therapy appointments and see children with ADHD and do some type of individual talk or play therapy. Reserach shows this is not effective, but this is what parents expect and I have no problem getting reimbursed for this. It is a procedure with a known billing code (90806) that every insurer will pay.
Now if I were to offer an evidence based treatment, such as a parent group with a curriculum on behavior management, there is no biling code I can use. Group therapy (90853) says I have to see the child in a group, not a parent. If I have another therapist do another group with the kids at the same hour, I could bill for that group therapy, but I am still stuck with no code for the parents. I could use multi family therapy (90849), but hardly any insurer will pay for this.
Our system of reimbursement is set up entirely with an adult, individual or group therapy focus. It is not set up (CPT codes) for evidence based work with children. There will be no effective dissemination of these practices until we change the systems in place for reimbursement.
I agree with Dr. Arnold’s concern about the backwardness of top down dissemination of knowledge. The modern reality of child mental health practice is that clinicians in the field often try new medications and treatment approaches long before they get formally tested in a funded academic study. In that process, they gather a great deal of useful information about what works and what does not, and what the risks may be of various treatments, although they do not typically gather it in a systematic fashion, the way “scientists” do in funded studies. This very rich fund of knowledge exists out there, but it is not effectively tapped by the scientific community, and not shared systtematically even within the clinical practice community.
However, in the modern internet-connected age, there is no reason that community clinicians could not participate in useful studies by pooling their experience in some form of online collaboration. Just as open-source software projects build terrific applications faster than “vertical” companies can develop, debug, and market a project in their own development department, it should be possible for clinicians to work together, in an open-source paradigm, to develop useful empirical evidence about their early experience with new treatments. Of course, the larger scale more rigorously designed and executed studies would still be necessary to convince the FDA that drugs are safe and effective. But having such a systematically pooled knowledge base open to the practicing community much earlier in the process of information growth could dramatically speed up the process, so that it would not take 18 years to inform the field about useful treatments.
Just as the FDA seeks drug event reports after a new medication is marketed, an online database could be created to anonymously follow early “trials” of new medications in children treated in the community by non-researchers who wish to participate in developing the knowledge base. Such data would not be perfect in the sense of well-designed controlled trials, but it could also answer some real-world questions about the risks and benefits of a particular treatment that ivory tower trials, with much more restrictive inclusionary and exclusionary criteria, could never answer.
Another advantage to such an approach is the ability to gather large amounts of useful information about drugs that are unlikely to be studied in a rigorous fashion, because they are older, off-patent, or represent a novel approach that has never been considered. It also allows some examination of medication interactions that would never be done in a controlled trial. In the “real world” of patients being hospitalized and discharged on multiple different medications from multiple drug classes, having a large “naturalistic” dataset could inform us in ways that no ivory tower study ever can about how various combinations of medications work together or against each other.
We need to rethink the way science is done in the 21st century. The opportunity for everyone practicing in the field to become a participant in research will revolutionize the way we approach clinical questions. How do we do this, within the constraints of a daily busy practice? What would motivate a busy clinician to participate in such an endeavor for little or no remuneration? Those are more difficult questions to answer than the purely mechanical and logistical ones of how do we create a database for sharing information. But none of them are insurmountable problems, if we think of new and creative ways to work together.
Peter,
Let me share with you the approach I have used in my work to advance new ideas and change professional behavior. First, there needs to be not only documentation of the problem, but a campaign to increase awareness of the problem — a communications plan with targeted messages to each of the key audiences. Second, there needs to be some agreement on the solution(s), and that agreement needs to be codified in some fashion by one or more “official” organizations or bodies as the standard of care. It also is important that the degree of adherence to that standard can be measured. Third, practitioners will need assistance achieving that standard of care so it can become standard care. This means not only providing education, models of best practice and clinical tools, but cataloging the barriers to achieving that standard and formulating ways to overcome or work around them. Finally, there needs to be efforts to shape public policy, primarily but not exclusively related to reimbursement, that support adoption and sustaining the desired new professional skills and behaviors. I believe that all of these steps are essential and to some extent must be worked on simultaneously.
I agree with Ed Schor’s points. However, part of the problem is that the disciplines tend to answer only to themselves and their Boards of Directors and memberships, rather than primarily to patients’ and families needs. We rarely get their feedback, in terms of what they want to fix the system, and no one brings all the critical stakeholders together to get the necessary agreements, design the tools, do the training and dissemination of the new methods, and empower those persons to continue this process in their communities, keeping them updated in real time, just like our software gets automatically updated from the web overnight!
I hate to talk about cars, given what Detroit is going through, but if the health research programs were like car factories, all that would be happening would be cars sitting on lots. While the major car companies (the researchers at universities) would be talking to each other, showing each other their cars, their real activity is debating whose car was best at annual meetings of the manufacturers, and continuing to tweak the cars’ versions on the factory lots. If car manufacturing were like health care research, there would be no car dealerships, no support or connections between the manufacturers and dealers to keep the dealers trained, updated and totally in the loop. So no one would have cars, though every now and then a horse dealer would hear about evidence-based trasnportation (cars) and wonder, but when some came to him for their transportation needs, he would give them a horse and buggy.
But health care research applied the lessons of business, it would first do market research…the investigators would leave the lab, go out and talk to clinicians like Doug Tynan or Steve Dummit, or to parents and families, and find out what they wanted, before designing something no one wants or would buy. And those practicing clinicians (like car dealers in the real world) would be try out and report new innovations, perhaps even being incentivized to pass the innovations back to the factory, but they would not be expected to become a factory…
Like car manufacturers, health care factories (researchers) should offer some help and guidance for setting up new dealerships, and support for marketing their wares to their local customers. Like cars, the health care manufacturer should stop by dealers often, to see if the dealer has problems, and spot check for ongoing quality.
Except in HMO’s, I don’t think anything in health care comes close. We have a vast, organizational and infrastructure problem.
Expanding on the car dealership analogy, while have no car dealers in child mental health research, and all of the research is sitting in the lot, in fact, it is even worse: Only prototypes are in the lot, and none have been adapted for roads and drivers in “the real world.” pj
I think Steve Dummit has an excellent idea. I had similar thoughts about the internet allowing all clinicians to contribute to data collection and epidemiology. A doctor friend asked where will the time come from to contribute? How will confidentiality be maintained?
I also thought of a web or email program to help people stay on their drugs, to contact them when their mood changes and they want to quit without consulting the doctor. A daily anonymous question–did you take your daily dose? Responses scanned automatically for those either saying no or not responding, then followup by a counselor after x days off.
The following remarks I sent to the Reach Institute as an email, revised to be more anonymous so as to prevent any insurance problems.
I heard Dr. Jensen speak and was inspired by your program.
Your ideas get to the root of current problems, dissemination of effective
treatment strategies, mode of delivery, and engaging the parents. The lack of
trained professionals can be addressed by both having more professionals and
also by training at different levels, from the bottom up. The absence of
disease is not the equivalent of good health.
I believe that teaching emotional literacy and communication skills are the best
prophylactic for mental illness prevention and modulation. They can be taught
to children and parents, and the books Parent Effectiveness Training and How to
Talk so Kids will Listen and Listen so Kids will Talk have helped me slowly
change my parenting style. However, I did not come to these books until my
children were entering middle school, because there is no guide to which books have the useful
message and which are the same well-traveled roads to perdition. Here is where
your dissemination would help, and I encourage you to think not just about
disseminating to the high end (Psych, family doctors) but the middle (social
worker, teacher) and low (parents and children) those practices which work.
Unfortunately, the program is a drop of water in an ocean of need. However, it
is great to hear that the seeds are being planted. The stigma of mental
illness also creates a barrier in acceptance and treatment. While the medical
community may have evolved to accept the disease model of mental illness, the
change in society is slower. One idea I had was to contact famous celebrities
who have suffered from mental illness to support your cause and also publicize
it, like Christopher Reeve and spinal cord injury. How about the Wilson
brothers and mood disorders? They could be wonderful spokespeople if they are
able to speak honestly about the disorder.
Finally, I want to continue to encourage you in your work. There are many of us
working in different ways to “Be the change you want to see”. I have witnessed
the destructive power of untreated and poorly delivered treatment of mental
illness, the unfulfilled potential in individual lives and the suffering that
radiates out like a stone dropped into a pond. I also know the medical
community has a ways to go, from the experience of my relative, who has
a mood disorder with conflicting diagnoses. During a depressive episode, she
had an accident which left her paralyzed. In the hospital, the brain
trauma resulted in temporary dementia and delusions, added to her continued
depression. The doctors treating her spinal cord injury were willing to talk
openly, while the psychiatrists asked us in for an extended family interview,
but would not discuss her condition for confidentiality reasons and didn’t
explain to us her dementia. That kind of behavior only reinforces the stigma,
the secrecy. When we contacted the psychiatrist who had seen her before the
accident, he did not want to see her, as he said they would likely fall into
the same pattern again. He had a point, but I was deeply hurt that he wouldn’t
make the effort to visit a patient who had reached the nadir of her life. For him, she may be a bad
outcome, but what about us, the family? He will not feel the pain that we
feel; he does not have to face the fear of losing a loved one.
Again, I thank you for the work you are doing to reduce the burden of human
suffering with science and compassion. What starts in the head and in
the heart, changes our world.
[Much to my delight, most of what I say here has already been voiced in some way by others in this blog…]
As one of the original contributors to this blog, my medical issues continue to keep me from real-time interactions. Nevertheless, most of the comments were right on point regarding the time for change being now (as Peter Jensen states.) Examples of a few hot spots touched upon are why we have failed to be riding the crest of cultural dialogue in 21 century Neuroscience. Pediatric Psychiatry’s obvious need to translate our effectiveness to all levels of culture is essential and never has there been a more suitable opportunity as now. We must ask how our behaviors contribute to the problem of making acceptance of our advancements in scientific data difficult for the scientific and general public to accept. Has the profession’s fuzzy manor of communicating the effectiveness of stimulant medication created mistrust in our practices? I suggest we must be more forthcoming in explaining the empowering aspect of improved self-regulation which leads to more compliant behavior rather then emphasizing the controlling aspect of better behaved children.
One of you brought up the inevitable ethical and legal collision between cognitive neurology and ADHD in direct opposition with the antiquated views of psychoanalysis and “acting out behavior” that has already begun heading quickly into the litigation pipeline with poisonous social consequences. None of the professions have been willing to look this monster in the face and deal directly with Eurocentric cultural bias toward folk psychology – perhaps the time has come to be direct on internalizing versus externalizing conflict for our children. The controversy between social learning and genetic predisposition has been long replaced with by a more complex, scientifically based idea of our genetic foundation being shaped and fitted through interaction with multiple pathways of culture, family, language development, socio-economic factors, race, gender, and the general goodness of situated fit within society.
I also think Peter Jensen will make an ideal spokesperson for breaking through the stereotypic cultural membrane which modern Pediatric Psychiatry has found itself on the outside for too many years. He has the intellect, understated charisma, authentic caring, and academic capital for the role. The move to change must address the issue on a variety of levels, side stepping the immediately allied domains (where a rigid polarized relationship has existed) and thus begin considering new, more varied, and novel venues for making the message vital. We must also choose high communities to assure the message is natural embedded within a locality that Peter may easy reference.
With the current evidence-based integrated, collaborative Multimodal Treatments managed over a sustained life trajectory, the field has entered into applied social neuroscience for community assessment as no other mental health domain as yet to succeed. We have become an oddly hidden resource which is currently capable of addressing numerous socio-cultural problems, yet we exist without the notoriety the services deserve. I believe the problem lies with our own limitations in self-concept and subtle, socially embedded presuppositions about our intrinsic limitations which we along with our allied fields, reflexively overlook our accomplishments in achieving the existing solutions.
When I started in the field 35 years ago, very little could be offered as effective treatment with severely disruptive and emotionally disturbed children and their families. Like magic, insoluble problems that confounded my practice 15 years ago are now quickly resolved and family stability can actually be achieved with lasting results. Why has this phenomena drawn more conflict then appreciation among the masses and scientist alike? How do we end up in stale old and ill-suited stereotypes when our accomplishments have been so great? As was hopefully imagined as recently in the 1970s, we have succeeded in locating a symptom cluster from the general population, called ADD in 1980 (an unfortunate error in retrospect), and fulfilled what was only a futuristic wish among scientists. The disorder was defined roughly from a genetic standpoint, and has had its developmental trajectory of morbidity followed for over thirty years, isolated its epidemiological topology, longitudinally tracked its genetic manifestation, begun to sort out its environmental determinants from genetic predisposition, had isolated effective pharmacological treatments as well as psychosocial intervention, built a topology of associated cognitive/behavioral affiliates , and clarified the neuro-physiological functions of the “disorder”- monumental feats in a surprising short period of time.
Likewise, the social relevance has become of national importance as returning veterans bring home what Colin Powell refers to as “America’s greatest public health epidemic among soldiers” with their impairment manifesting largely as executive dysfunctions. The VA hasn’t the slightest idea of executive dysfunctions and their treatment. I participated in a recent ADDA telecast where the RVA psychologist literally pleaded for ADHD Coaches to assist the VA in their care. She claimed 20% of returning vets have documented preexisting ADHD and suspect another 10% are not recognized. Compounding the problem is 40% of all returnees have been exposed to TBI concussions which exacerbate or cause executive dysfunctions with as many meeting criteria for PTSD (they established ADHD as a vulnerability to combat trauma) and obfuscates the clinical picture. The soldiers, who often joined between ages 17-19, are having adjustment problems at home and return in worse shape with families expecting them to have matured with greater self-regulation competency and prepared to return to school and assimilate into family life. The complex of Adjustment Disorders upon their return lead to personal difficulties accompanied with skyrocketing rates in domestic violence, drug abuse, and self-destructive behavior. The suicide rate for the military in 2009 is expected to run over 200, the largest in the military’s history. The public needs a construct explaining PFC-S neurology and the executive control system or they will, by default, retreat to folk psychology which relies upon individual blame instead of a coherent neuroscientific explanation.
The signs for a change surround us and it is incumbent upon those of us who have a contemporary grasp on the problem to step forth and speak up.
I firmly agree that our present healthcare “sysytem” is not a system but a patchwork of various strategies and programs theat fail to work efficiently. Not only does this approach fail to address public health perspectives but even individual care is fragmented and inefficient. The curreent “patch” being considered by Congress will not alter this pattern and does not constitute anything more than another patch.
Strategies that might be taken at the federal level to effect real reform are limited by political inertia and entrenched interests. HOwever, the goals should be aimed at 1) improving access for everyone, including unregistered aliens, 2) improving efficiency which incluted timely intervention, prevention measures and reducing unnecessary care, and 3) improving quality of care, which you have so well advocated for.
From a political standpoint, I don’t think a frontal assault, e.g., the Clinton and Obama approach, will succeed. I think we need a back door approach that will greaduall move the healthcare system toward these goals. Even though I am a part of the fee for service part of the current system, I think that an integrated organization model, such as Kaiser-Permante or the VA, has a much better chance of achieving these goals. It may be possible to encourage the development of community non-profit medical clinic, which currently suffer on the quality aspect of these goals, that would allow a gradual shift away from the usual fee for service system as people and sponsoring companies found typical insurance too expensive and not as desirable as a more efficient, and therefore less expensive, alternative. Federal support of these non-profits would necessarily need to include parameters for EBM and other quality of care markers.
However, there are other pressing needs particulary manporer shortages in primary care, nursing, child psychiatry, and others. The federal govt. could target support for individuals to go to medical or nursing school and to enter into these areas with a payback, perhaps five years, to work in an approved non-profit clinic providing care in underserved ares or to underserved populations. Salary support for these individuals may also be needed.
These are just some of the ideas that might allow a “backdoor” approach that would gradually alter the system in a positive direction.
I am no longer in practice–having gone over to the “dark side” as some would say. From an inside the industry perspective, there is an appropriate barrier between the scientific community publishing results of medical research and the marketing community which is not really in a position to establish that new car lot where products and information are so intimately entwined. And where the scientific community in industry has stepped out to influence prescribing behavior apart from publications and presentations, we get into the situations like the Phen-Fen and the Neurontin debacles.
Therefore the suggestions for clinican-based web site interactions, separate from the actual presentation of research findings and sponsorship by the industries that may have conducted many of the clinical trials, would have real value. Even some of the “ivory tower” research is, ultimately, funded or supported by industry–though there are exceptions.
Clinician-developed internet communication, as suggested by Steve Dummitt, would be useful, though there would be risks:
1. Who would be responsible for accuracy of the information? (Wikipedia is not always a reliable source)
2. How would concensus build that a treatment or approach was indeed what should be a standard of care? (Is dissension poor practice, or is there still much “art” in medicine?)
3. I am a believer in real-world outcomes but would thought leaders have to get past the concept of double-blind, placebo-controlled designs as the sole source for evidence-based conclusions? or, phrased differently, who will be first to sign up for the DB, RCT of the parachute?
4. While I recognize that industry is not in a position to manage such a knowledge-sharing venture (FDA very strictly limits the nature of communication between industry and physician, which is why y’all receive those “dear doctor” letters), would things be any better if the third-party payers, or a government agency managed this, or does it truly have to be a grass-roots, physician-driven enterprise?
5. One suggestion I would make is that it be physician-driven and that it focus on communication among physicians rather than with patients/public–not that I am anti-consumer, but rather the amount of information that would need to be communicated, and the depth of detail, would preclude dissemination to the public in any format that could truly be grasped. Such further dissemination could be through support organizations such as CHADD.
Just some brief thoughts on the topics in this blog.
Dr. Babcock makes excellent points about the separation between industry and physicians’ prescribing practices. Evidence-based treatments, for the “evidence” to lasting and credible, also have to vetted through clinical experiences, as well as non-industry-funded double-blind clinical trials (DB RCTs) through independent funders such as NIMH and foundations are critical. Physicians’autonomy in arriving at independent decisions about what constitutes evidence-based practices, perhaps by consensus guidelines of groups of expert clinicians and researchers is needed. Professional and family advocacy organizations, as well as other non-profit bodies such as the REACH Institute can often help achieve the objective of identifying what constitutes evidence-based treatments.
Unfortunately, the story doesn’t end there. According to the Institute of Medicine it often takes well-intentioned physicians a long time to adopt new, optimal treatment practices (17 years!), particularly since they are running a busy private business enterprise. What they learned in medical school and through subsequent clinical experience may seem to be working just fine, and they may have little reason or time to try a new, supposedly better approach, particularly if they are not getting corrective feedback from patient outcomes that are not rigorously monitored. They also may not see enough patients to actually examine comparative outcomes between various treatments they use.
One partial solution, of course, it the ongoing gathering of valid, reliable outcomes measures, maybe not just from their own practice but coalitions of MANY doctors using similar and different approaches. This is a virtual impossibility for the solo on small group practitioner, and only achievable currently in large organizations such as Mayo (where I work), or other healthcare organizations such as Kaiser Permanente or Group Health. Electronic medical records can be helpful, but only if the data are regularly mined, with tracking of patient outcomes and feedback of comparative results to all clinicians.
pj
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