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Comprehensive Care for Complex Patients: The Medical-Psychiatric Coordinating Physician Model

by Steven A. Frankel,James A. Bourgeois, and Philip Erdberg. Cambridge, United Kingdom, Cambridge University Press, 2012, 201 pp., $90.00.

Reviewed by Robert J. Boland, M.D.
Am J Psychiatry 2014;171:373-374. doi:10.1176/appi.ajp.2013.13101331
View Author and Article Information

The author reports no financial relationships with commercial interests.

Dr. Boland is a Professor in the Department of Psychiatry and Human Behavior, Brown University, Providence, R.I.

Accepted October , 2013.

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In one sense, the title says it all. It introduces the reader to what will be the foremost themes of the book. How can we provide comprehensive care in our modern health care climate? And how should this help us to treat our more complex patients? The answer to both, according to the authors, is in the subtitle: by using the medical-psychiatric coordinating physician model.

But what is meant by “comprehensive care”? In explaining this, the authors consider the way health care was, how it is, and what it could become. Historically, health care was a dyad: the doctor-patient relationship. Although we may yearn for this romantic image, it is clear that the days of the country doctor who meets all of his or her patients’ needs are long gone, and in the modern era, the health care system comprises a large team of various primary care and specialist doctors, as well as an assortment of various other professionals. Although this heath care team is, ideally, all very impressive, in reality it is a mess. There is usually little effective communication between different providers, and the various treatments prescribed occur independently of and, at times, at odds with one another. With this in mind, the authors sketch out a plan for the future, one of coordinated care in which the providers can function like a true team.

And what are “complex patients”? Initially, they are defined as patients whose symptoms do not respond to our “normal” medical approaches. This is often because their medical illness is complicated by psychiatric factors. However, the authors soon expand this definition to include the many other types of complexities, including various psychological, social, and systems issues that can affect the straightforward delivery of care. As they broaden their definition, we begin to wonder which patients are not complex. One is forced to consider the possibility that the only patients who are “straightforward” are the ones we haven’t thought about enough and that “simple” patients represent a figment of our failed imaginations.

Much of the book is devoted to describing the importance of collaborative care, and there is already a good deal written about this subject. So what makes this book different? The answer is in the subtitle: the concept of the medical-psychiatric coordinating physician model (or MPCP; beware, as there are a good deal of unfamiliar acronyms of which the reader will have to keep track). Every team needs a leader. In many of the current collaborative care or medical home models, psychiatrists are relegated to the sidelines. However, the authors suggest that psychiatrists’ unique skill set makes them the ideal persons to integrate the many data points our system generates into a coherent narrative. If some of the unconverted ever hear this sermon, this book might stir some controversy. That said, the authors back up their contention with example after example of how psychiatrists are best suited to appreciate each level of complexity that may challenge a treatment team.

Along the way, the reader is introduced to important techniques and concepts meant to guide the budding medical-psychiatric coordinating physician model, including the concept of “tuning,” which means using varied bits of objective and subjective information to hone in on the “truth” of what is really going on with a patient, and SOPA (self-other rapid assessment), a method for monitoring oneself and one’s treatment, as well as various strategic approaches for dealing with patient (and sometimes practitioner) resistance.

This method of operationalizing one’s approach to complex patients is reason enough to read this book. However, the book also serves a greater purpose. Here, the title does the book an injustice, as it gives one the impression that this will be a somewhat dry, technical manual. What a surprise then, to encounter the book’s disarmingly engaging prose. The tone is often conversational, even mischievous at times, often written in the first person and addressing the reader directly—the prose feels more like the transcript of an unusually erudite soliloquy from a gifted colleague (although there are three authors, it is largely written with a single voice). This is a book meant to be enjoyed cover to cover.

Perhaps most compelling are the exquisitely rendered case studies employed throughout the book. For those who bemoan the loss of this art, rest assured, the authors here present robust cases, full of nooks and crannies that are unfailingly honest in their depiction of the foibles of both patients and doctors. The cases are put to excellent use, and the authors frequently return to them throughout the book to illustrate increasingly deeper points.

Who should read this book? Most practically, it is aimed at those interested in psychosomatic medicine and collaborative care, as the book focuses on the complexities that lie on the (imaginary yet practical) body-mind interface. However, this book serves a greater purpose as it meditates on the doctor’s role in modern medicine. My sense is that medical students, residents, and many of my colleagues all hunger to see themselves as more than useful technicians in the machine that is modern health care. This book helps us refocus on what it means to be a true healer.




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