The Silo Effect

Howard s. King, MD, MPH
November 12, 2012

Ed. Note – Over time, I have tried to provide parity between physical and emotional aspects of care. Up to now I have been able to do both with equal justice. But it has become an increasing challenge, given how advocates of physical care insist they deserve priority. Isn’t there room for compromise?

I was once taught the following by two professional friends. I asked one of them why psychosocial concepts are not taught more comprehensively by teachers in pediatric residency training. He replied with as adequate an answer as I’ve ever heard.

Most teachers weren’t taught these concepts in their own training. How can you teach what you never learned yourself? Beyond that, there are tasks young physicians must also do for their chiefs before achieving their own goals including mastering the skill of psychosocial assessment.

Consider three common pediatric responsibilities. One is the appropriately highly valued documentation for the longitudinal medical record. Who could dispute the many benefits derived from such documentation? While it takes much time, it saves money from reduplication of testing, informs our colleagues what and why we have chosen to do for our patients, as well as other benefits. Which of the many innovations would we omit?

We have one of the best vaccination programs in the country. We are audited every other year and some requirements seem indispensable. We must document three months of twice daily refrigerator and freezer temperatures, initialing each recording. We must be sure no vaccine has expired and record the name of the product. Have we passed out information forms to parents for each vaccine we administer and noted insurance information for each patient? Each requirement is necessary. None could we omit.

Compare those two programs and requirements with what we ask physicians to do for psychosocial assessments. The answer for most is to ask parents to take ten minutes while waiting to be seen during which they fill out a pediatric symptom check list. We review this list as part of our 15 – 20 minute visit and that provides a comprehensive assessment. We ask each family to elaborate the symptom check list and, hopefully, we will make a timely and empathic referral.

Conclusion: Each task is very important. But there is no question that the first two receive a higher priority. What do I wish we could do when we conclude there is no way we can find the time to do each with the same degree of excellence? I wish we could discuss the challenge of choosing between good documentation; good vaccinations, and achieving parity between physical care and mental health care.

If representatives from each group could listen to their peers with compassion, I am sure we would find a solution that does justice to the responsibilities which confronts every physician. I have concluded that providing good mental health care sometimes comes up short in our priorities because some are skeptical of its value.

If we could find adequate time for a mutually respectful discussion, I believe we could find an antidote to “the silo effect” and positively impact the quality of care we provide.

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I would like to thank the following for their generous support, without whom this web site and training program would not exist: The Sidney R. Baer, Jr. Foundation, The Alden Trust, the Commonwealth of Massachusetts Department of Mental Health, Project INTERFACE (Newton Public Schools and the U.S. Department of Education), the Locke Educational Fund at Newton- Wellesley Hospital, Aetna Health Plan, the Kenneth B. Schwartz Center,  and the families of my medical practice. 

I hope you find this site useful and encourage any comments.

- Dr. Howard King, M.D.