Hello!
Day, what, 120-ish of the global COVID-19 pandemic and I haven't written a post since March 27th when I talked about accepting this BS situation we're in. I guess I've been kind of distracted.
Today I'm not here to talk about COVID. Except at the end and not in a way you'd probably expect. Today I'm here to tell you why you don't have access to a psychologist who specializes in helping patients living with chronic digestive diseases.
I've been at this "psychogastroenterology" thing since 2005, when I was a wee pup in my 2nd year of graduate school. Before we even had a name for the field, rather we were just a few clinical psychologists with training in chronic diseases (i.e. clinical health psychology) that noticed many people with GI conditions needed a lot of help navigating things. And the stigma, oh the stigma, especially toward patients with irritable bowel syndrome. It was my first research project because it was so glaring.
Since then, psychologists have slowly - and I mean slowly - made inroads into the mainstream GI academic world. We get invited to speak at conferences. We sit on committees and editorial boards for journals. We have a unique division of the Rome Foundation, which if you haven't heard is kind of a big deal in that they literally write the books on functional GI conditions to the point they recently renamed an entire class of illnesses to disorders of gut-brain interaction. Boom. Done. Renamed. FGIDs are now DGBIs.
We travel the globe spreading the good word about how a GI psychologist can be integrated into GI practices and look at these metrics on improved outcomes!
People love metrics.
Point is, in the academic world we've made it. Kind of. Ok, we're basically B-list actors. Gastroenterologists are Tom Hanks and we're his kid, Colin. But hey we'll take it. In the clinical world, you know where patients live and breathe, it's still a vast wasteland of access to these services. If you don't live within a reasonable distance to a major academic hospital in the United States (don't get me started on the rest of the world), well, my friend, you are shit out of luck. Why is this happening? Here are a few big reasons.
Money
Like it or not, most medical systems want to make a profit. Even those who are "not for profit" need to make money to pay for everything. And if you haven't been paying attention, medical care in the United States if fucking expensive. We're not going to get into all of that, but in a system that needs cash psychologists fall short. We are reimbursed significantly less than physicians by insurance and we see fewer patients in a day because we spend around 45 minutes per patient versus 15 minutes. We also don't perform more expensive things like endoscopies and colonoscopies. So it's really hard for us to show value when we can barely cover our salaries and overhead with the revenue we can generate.
Stigma
This is a big one. There's a very long history of stigma toward mental illness in the world. Referring a patient with a medical problem to a psychologist takes skill. When done poorly, it can be catastrophically bad. Patients may take offense to the notion of being sent to psych and being labeled "crazy" and if there's very little explanation as to why they're being referred, why wouldn't there be offense? But the fact that having any sort of mental distress, let alone mental illness, can be offensive is part of the bigger systemic stigmatization toward those with mental illness.
Even though on paper a psychologist may look good to a gastroenterology practice, there seems to be some discomfort with our presence by some MDs. No, we're not constantly analyzing you. Think of how exhausting that would be, seriously. But patients do talk to us about their other doctors and sometimes they don't have very nice things to say. I can see how that might make some people uncomfortable. Like we're the recipient of the town gossip. But we are trained so heavily on ethics and compartmentalizing the information we are deemed worthy to hold that we are able to bridge the worlds of our colleagues and our patients quite well and without judgment.
Space
Kind of related to money, space is at a premium in many medical practices. And if you need to decide whether to create another exam room or an office for a psychologist, you may opt for the exam room because of revenue demands. I've seen patients in exam rooms, in physician offices where I've had to put away other patient files prior to starting my day to avoid a HIPAA problem, and other less than ideal spaces. Whether in academic medicine or private GI practices, I've always heard "we're tight on space" as a barrier to having greater behavioral medicine presence.
Lack of Awareness/Interest in the Field
I want to say it's lack of awareness by psychologists that patients digestive diseases are in need of help, but I don't think it is. There is massive interest in obesity, cancer, and cardiology in the sub-specialty of healthy psychology. If I read the list of presentations of any major health psychology conference it's all of these areas. Gastroenterology is RARE. More recently groups from our field have pitched symposiums to the American Psychological Association annual meeting only to be rejected without much explanation. I mean, I guess I get it. Not many people want to talk about bowel function as part of their job (there's that stigma again). But I've worked with patients with a myriad of other conditions and they all have their difficult content. So why can't we talk about poop? Bottom line is there simply aren't enough psychologists trained in psychogastroenteorlogy. We're trying, but again, excruciatingly slow.
Insurance Coverage
I put this last even though this is the #1 reason I hear people cite why they don't have a psychologist they work with to treat their patients with digestive disease. "They don't take insurance" or "Insurance doesn't cover it." I'm here to say this is outdated information. I fully acknowledge that insurance is a barrier to access to care. Some plans do not have mental health coverage as a whole. Medicaid doesn't cover our services even in an academic hospital. Absolutely there are insurance issues. However, many psychologists DO accept insurance. I am paneled on 7 different major plans, including Medicare, as are the four other clinicians in my practice. And guess what? The vast majority of the time, like 98% of the time, we have no issues with insurance coverage. AND since COVID-19 changes came into place, we can see people via tele-medicine without getting hit with lower reimbursement, which was definitely a thing in the "before times." We are hopeful these changes will stay in place permanently so we can broaden our reach. I can see people 5 hours away in the tip of southern Illinois now. Access!
These are my observations and opinions from the last 15 years of my experience working to create and promote behavioral medicine services in gastroenterology practices. I welcome further discussion but I really want to figure out how to FIX the access issues. COVID-19 induced technology changes will certainly help. Engagement by major stakeholders in the GI space will help. This includes patient advocates, physician thought leaders, and pharma. I feel more optimistic than I have in a long time. Which is a weird thing to say in the midst of a global pandemic. If you want to join in this fight, please reach out to me via Twitter DM (@DrTiffTaft)
--T2
Day, what, 120-ish of the global COVID-19 pandemic and I haven't written a post since March 27th when I talked about accepting this BS situation we're in. I guess I've been kind of distracted.
Today I'm not here to talk about COVID. Except at the end and not in a way you'd probably expect. Today I'm here to tell you why you don't have access to a psychologist who specializes in helping patients living with chronic digestive diseases.
 |
| My kids have been playing a shit-ton of Minecraft |
I've been at this "psychogastroenterology" thing since 2005, when I was a wee pup in my 2nd year of graduate school. Before we even had a name for the field, rather we were just a few clinical psychologists with training in chronic diseases (i.e. clinical health psychology) that noticed many people with GI conditions needed a lot of help navigating things. And the stigma, oh the stigma, especially toward patients with irritable bowel syndrome. It was my first research project because it was so glaring.
Since then, psychologists have slowly - and I mean slowly - made inroads into the mainstream GI academic world. We get invited to speak at conferences. We sit on committees and editorial boards for journals. We have a unique division of the Rome Foundation, which if you haven't heard is kind of a big deal in that they literally write the books on functional GI conditions to the point they recently renamed an entire class of illnesses to disorders of gut-brain interaction. Boom. Done. Renamed. FGIDs are now DGBIs.
We travel the globe spreading the good word about how a GI psychologist can be integrated into GI practices and look at these metrics on improved outcomes!
People love metrics.
Point is, in the academic world we've made it. Kind of. Ok, we're basically B-list actors. Gastroenterologists are Tom Hanks and we're his kid, Colin. But hey we'll take it. In the clinical world, you know where patients live and breathe, it's still a vast wasteland of access to these services. If you don't live within a reasonable distance to a major academic hospital in the United States (don't get me started on the rest of the world), well, my friend, you are shit out of luck. Why is this happening? Here are a few big reasons.
Money
Like it or not, most medical systems want to make a profit. Even those who are "not for profit" need to make money to pay for everything. And if you haven't been paying attention, medical care in the United States if fucking expensive. We're not going to get into all of that, but in a system that needs cash psychologists fall short. We are reimbursed significantly less than physicians by insurance and we see fewer patients in a day because we spend around 45 minutes per patient versus 15 minutes. We also don't perform more expensive things like endoscopies and colonoscopies. So it's really hard for us to show value when we can barely cover our salaries and overhead with the revenue we can generate.
Stigma
This is a big one. There's a very long history of stigma toward mental illness in the world. Referring a patient with a medical problem to a psychologist takes skill. When done poorly, it can be catastrophically bad. Patients may take offense to the notion of being sent to psych and being labeled "crazy" and if there's very little explanation as to why they're being referred, why wouldn't there be offense? But the fact that having any sort of mental distress, let alone mental illness, can be offensive is part of the bigger systemic stigmatization toward those with mental illness.
Even though on paper a psychologist may look good to a gastroenterology practice, there seems to be some discomfort with our presence by some MDs. No, we're not constantly analyzing you. Think of how exhausting that would be, seriously. But patients do talk to us about their other doctors and sometimes they don't have very nice things to say. I can see how that might make some people uncomfortable. Like we're the recipient of the town gossip. But we are trained so heavily on ethics and compartmentalizing the information we are deemed worthy to hold that we are able to bridge the worlds of our colleagues and our patients quite well and without judgment.
Space
Kind of related to money, space is at a premium in many medical practices. And if you need to decide whether to create another exam room or an office for a psychologist, you may opt for the exam room because of revenue demands. I've seen patients in exam rooms, in physician offices where I've had to put away other patient files prior to starting my day to avoid a HIPAA problem, and other less than ideal spaces. Whether in academic medicine or private GI practices, I've always heard "we're tight on space" as a barrier to having greater behavioral medicine presence.
Lack of Awareness/Interest in the Field
I want to say it's lack of awareness by psychologists that patients digestive diseases are in need of help, but I don't think it is. There is massive interest in obesity, cancer, and cardiology in the sub-specialty of healthy psychology. If I read the list of presentations of any major health psychology conference it's all of these areas. Gastroenterology is RARE. More recently groups from our field have pitched symposiums to the American Psychological Association annual meeting only to be rejected without much explanation. I mean, I guess I get it. Not many people want to talk about bowel function as part of their job (there's that stigma again). But I've worked with patients with a myriad of other conditions and they all have their difficult content. So why can't we talk about poop? Bottom line is there simply aren't enough psychologists trained in psychogastroenteorlogy. We're trying, but again, excruciatingly slow.
Insurance Coverage
I put this last even though this is the #1 reason I hear people cite why they don't have a psychologist they work with to treat their patients with digestive disease. "They don't take insurance" or "Insurance doesn't cover it." I'm here to say this is outdated information. I fully acknowledge that insurance is a barrier to access to care. Some plans do not have mental health coverage as a whole. Medicaid doesn't cover our services even in an academic hospital. Absolutely there are insurance issues. However, many psychologists DO accept insurance. I am paneled on 7 different major plans, including Medicare, as are the four other clinicians in my practice. And guess what? The vast majority of the time, like 98% of the time, we have no issues with insurance coverage. AND since COVID-19 changes came into place, we can see people via tele-medicine without getting hit with lower reimbursement, which was definitely a thing in the "before times." We are hopeful these changes will stay in place permanently so we can broaden our reach. I can see people 5 hours away in the tip of southern Illinois now. Access!
These are my observations and opinions from the last 15 years of my experience working to create and promote behavioral medicine services in gastroenterology practices. I welcome further discussion but I really want to figure out how to FIX the access issues. COVID-19 induced technology changes will certainly help. Engagement by major stakeholders in the GI space will help. This includes patient advocates, physician thought leaders, and pharma. I feel more optimistic than I have in a long time. Which is a weird thing to say in the midst of a global pandemic. If you want to join in this fight, please reach out to me via Twitter DM (@DrTiffTaft)
--T2