Collaborating with occupational therapists: a game-changer for behavioral health [PODCAST]

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In this episode, psychiatrist Maryna Mammoliti discusses the importance of collaborating with occupational therapists. Occupational therapists are health care professionals who can help assess and accommodate patients’ daily activities, including work and home life. Maryna shares her experiences working with occupational therapists and how they can assist physicians in making evidence-based decisions on patients’ return to work process. Occupational therapists can also assist patients with ADHD, emotional regulation, social skills, and sensory issues. Additionally, they can help physicians with their own health by assessing cognitive and physical demands and ergonomic setups, which can increase efficiency and decrease burnout. Tune in to learn more about the benefits of collaborating with occupational therapists.

Maryna Mammoliti is a psychiatrist.

She shares her story and discusses her KevinMD article, “Discover the power of occupational therapy: a solution for doctors and patients.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today we welcome back to the show Maryna Mammoliti. She’s a psychiatrist. Her KevinMD article is titled “Discover the power of occupational therapy: a solution for doctors and patients.” Maryna, welcome back to the show.

Maryna Mammoliti: Thank you. I’m excited to be back a year later. I’m always looking forward to your articles and your show, so I’m glad to be back again.

Kevin Pho: All right, now for those who didn’t get a chance to listen to our first episode together, just briefly share your story and journey to where you are today.

Maryna Mammoliti: OK, so I’m a psychiatrist in Canada. I practice in Ontario, and I see a lot of physicians in my practice. I do community psychiatry. I also do emergency psychiatry in downtown Toronto at a hospital called CAMH. I also focus a lot on ADHD in the general population, but also in physicians, and on physician health. So that’s my psychiatric practice.

I also am a certified executive coach, and I work on boundaries and on career changes, so that’s my other thing. And I am a mom of four children, three cats at this point, which we collected during COVID, and a dog. So that’s a bit about myself. And what else? I was heavily involved in medical politics during COVID. I was representing psychiatrists with the Ontario Medical Association as the chair of the section, and I’m still involved in promoting physician interests through my involvement in our provincial association specific to psychiatrists in Ontario.

Kevin Pho: What are some of the biggest issues facing that specialty, and why is it so important for physicians to advocate?

Maryna Mammoliti: Well, I mean, I think the issues facing psychiatrists are very relevant to every specialty. One is burnout, right? Just yesterday I was connecting with my psychiatrist colleague, and we were just chatting about the acuity of our cases. Personally, my own patient load has been very acute. People are in a lot of crisis, a lot of need. I think every psychiatrist is facing a lot more acuity in our cases, just like, I think, any physician right now, whether it’s a family doctor or specialists. I think everybody is facing a ton of acuity in the patients we’re seeing.

So aside from the burnout from COVID that we all experience, because we’ve been in so much chaos and uncertainty every day, I think the patients we’re seeing need so much more from us when we already have so little to give, because COVID took so much. And so I think the challenge, number one, is the burnout from the acuity of the patients. Aside from that, again, there’s navigating the fractured system, because other people have burnt out in the system, whether it’s case managers or other therapists. Getting help for our patients outside of ourselves has been really hard, because a lot of people left positions and a lot of people have gone on leave.

And obviously compensation, because in Canada we are paid by the government, so compensation has always been a big issue for psychiatrists, because we’re usually one of the three lowest-paid specialties in Canada. So that’s always been a big part of it: How do we get compensated by the ministry? We just worked after hours during COVID because the need is so great. How do we compensate? How do we keep people in psychiatry? Because it starts with medical students. Medical students may not find psychiatry attractive because of the intensity and the low payment to cope with it, so it’s always hard to get students to be interested in psychiatry.

Kevin Pho: Now, when you talk about things like physician burnout, what’s the response you normally get from politicians and those who make the medical decisions affecting physicians when you advocate?

Maryna Mammoliti: I think it’s very different between the response we get and what actually happens. When there are interviews and whatnot, the response is always, “Oh, yes, we care.” But unfortunately, actually implementing systemic changes, or actual changes that would support wellness for physicians, is very different, right?

And I think in particular, again, I don’t know what it is like in the U.S., but at least in Ontario, the number of complaints against physicians has gone up. If you’ve noticed, all sorts of disciplinary complaints have gone up despite physicians trying to do their best. That in itself is adding to the burnout too, and I think to burnout for everybody, because you have extra paperwork when you’re trying to do your best. So I think even sometimes the punitive ways of dealing with physicians have been another issue out of COVID, when physicians are doing their best and they might not be able to meet certain deadlines or things like that, because it’s just not possible.

The insurance companies have been really difficult with all the paperwork, for example. I know it affected family doctors, and I know psychiatrists too. These insurance companies want updates every 30 days for somebody being off. I don’t have appointments to bring somebody back every 30 days just for insurance paperwork. I have patients to see. And then you get these angry emails and paperwork and all sorts of demanding emails from the insurance companies, threatening that they’re going to cut off the patient if you don’t see them in that short period of time.

That’s been a big issue, to be honest, dealing with the insurance companies for people who are off, because they have to come see their family doctor or psychiatrist. Somebody has to sign their paper, and the frequency of the paperwork signing has skyrocketed during COVID for us. So again, on the one hand, you talk about physician health and physician wellness, yet systemic changes to support that are very difficult. People taking a leave is very difficult. Finding coverage for a leave is very difficult. So yeah, it’s been absolutely difficult in terms of the platitudes versus action, the platitudes from politicians versus action to actually accommodate wellness.

Kevin Pho: All right, let’s talk about your KevinMD article, titled “Discover the power of occupational therapy: a solution for doctors and patients.” Wellness and insurance companies, right? How did this article come together?

Maryna Mammoliti: Well, first of all, I’m going to tell you up front that my really good friend is an occupational therapist, and how I became friends with him is basically because we shared a patient. We shared a patient who was returning to work, dealing with these forms, and she started seeing him to help her return to work. We connected, sharing information about the return-to-work process, and then I saw his work and he saw my work, which I really liked. I really trusted his work after seeing it.

And so I connected with him and had a couple of meetings. Then I shared patients with him more and more, and I really started relying on his recommendations to help me with the return-to-work process for my patients during COVID, particularly because the amount of paperwork that is thrown at me as a psychiatrist is absolutely unmeasurable. I cannot tell you. And so I started relying on his professional opinion, and our patients were getting better. Our patients were going back to work. So that really became a friendship. He’s a very close friend of mine.

We worked a lot on supporting people with ADHD, because ADHD is very poorly understood in the workplace, especially for physicians. So he sees a lot of my physician patients to help with return to work, because many workplaces where physicians work do not understand accommodations. They just don’t understand that a physician could still work with accommodations, especially for ADHD. One of the most common reasons I see physicians, and I start assessing them and it turns out to be ADHD, is charting issues. They get behind with paperwork. Charting issues are, again, so common and overwhelming.

I’ve had people get in trouble for charting. They’d get disciplinary action when it had been unrecognized ADHD, and their environment was never supportive of their ability to do charting in the first place. It was a conflict between the environment, unrecognized ADHD, and all the pressure and stuff, yet they were punished, right, with no supports. So we built a good working relationship, and we worked a lot on people with ADHD and return to work.

And also, I really rely on occupational therapists in managing my patients in return-to-work and impairment assessments. When people ask what their impairment is and whatnot, I really ask for that, and especially workplace assessments, because I can’t be with the patient at work. I can figure out how one’s depression might impact something, but I can’t be there with a police officer on the job and assess how their trauma is going to get triggered when they’re out at the station or out on the road. And these are the things that we’re being asked about when we return people to work: Is this person functioning? And sometimes safety, sometimes this.

It’s like, how can I tell you that, when most physicians have not had training on the occupational implications of any condition, let alone mental health? I’ve done a lot more work on this, so I have more skills to assess it, but mostly an average family doctor or psychiatrist does not have these skills, yet we’re asked to do that, right? And the same goes for physical function. Most physicians are not going to be watching how many steps a patient can take before they get short of breath. We don’t have the time. We don’t have the place. We’re not going to go outside with the patient and walk them down the street and watch them to say, “Oh, yeah, they can walk 50 feet,” or whatever. Yet a lot of these forms ask us these specific questions that I can’t really answer.

And so we don’t have the education. We might not have the ability to actually assess this objectively. I can’t go to somebody’s workplace and assess how they do in the workplace, because it’s outside of our scope. That’s not what physicians are taught to do. Yet insurance companies expect us to do this and then blame us if we can’t answer it to their liking, and then tell the patient they got a form rejected because “Your doctor didn’t do it right,” when in reality we did it to the best of the knowledge we have. And so occupational therapists help a lot with that.

So that’s how this article came about. I have a big thing with boundaries, like what are the boundaries, and I realized how much I rely on occupational therapists to help me maintain my professional boundaries, because I can’t answer questions I’m not trained in assessing, and this is what this paperwork often asks us to do.

Kevin Pho: What are some of the typical behavioral health conditions that you could refer to occupational therapists? Because I think there’s a perception that occupational therapists mostly deal with physical issues, but they can also handle a lot of the behavioral health issues as well. So what are some common behavioral health scenarios that you would send patients to occupational therapy for?

Maryna Mammoliti: Absolutely. That’s an absolute misconception, because occupational therapists are able to do physical and mental, so pretty much any condition, whether it’s depression, PTSD, ADHD, trauma, or schizophrenia. They have the skill set. And as I mentioned in my article, when I trained in my psychiatry residency, we had occupational therapists on inpatient, on outpatient, in so many areas, and the occupational therapists were working with such a variety of people.

When I worked in a hospital setting, we would rely on an occupational therapist to assess safety to be discharged home. Can people call 911? Can people manage a simple phone call? You would assess that in various populations; you would work with an occupational therapist to assess that. The physician didn’t do it, inpatient or outpatient, so I’m not sure why we’re expected to do that in the community when we don’t have the skills.

So occupational therapists have the capacity to address any of the DSM-5 conditions based on their training and experience, because there are occupational therapists who work with children versus the ones who might work with the geriatric population or the adult population. So they might have their own focus, but they usually are exposed to the full range of this.

Kevin Pho: So I want to talk about a scenario that you brought up, about a physician with potentially undiagnosed ADHD having problems completing charts. Why is it difficult for those with ADHD to complete charts?

Maryna Mammoliti: Perfect example. Why? First of all, let’s look at the environment. If a physician has no desk, no space, and is in the middle of a nursing station where you’re constantly interrupted, there’s constant noise. There’s noise from the computers buzzing, people talking, right there. The environment in itself could be so counterproductive for somebody without ADHD, let alone with ADHD, when that distractibility is huge and staying on task is hard because of ADHD, right? And think about where most of us chart: in a busy nursing station or an open space station. While we’re charting, we’re often interrupted by a medical student, by a nurse, by a phone call, by a page. There are constant interruptions, so for somebody without ADHD, it’s very difficult, let alone if there’s ADHD, right?

The other thing is we often don’t actually have working computers, or we have to find a computer. So even if we are trying to chart, we might not actually have access to a computer to chart, right? So there’s noise and lack of accessibility. The other thing is our patients come in with multiple issues. We have to document multiple different issues, no matter what your specialty is, right? And so people with ADHD might get distracted in trying to synthesize and spend a much longer time trying to write a note than they would otherwise. Or because they got distracted in the assessment, they might forget what the patient said, and they’ll try to trace back or remember what they said.

The other thing for doctors with ADHD is that they can get tangential. So let’s say they’ll be documenting on one issue, and they over-include everything that was said about that, and then they’ll get distracted and go off on a tangent, and then they take much longer to actually document their appointment, because they often get tangential. So there’s that too. There are often distractions, and there’s often also just the sheer exhaustion from having to pay attention when you’re not medicated and ADHD is not recognized. So they might feel much more exhausted at the end of the day, when people catch up on charts. And procrastination is a big issue in ADHD, so people will procrastinate and procrastinate until there’s some sort of crisis.

So for something like that, an occupational therapist could start with assessing, “What is your actual physical environment?” Because again, as physicians, we’re not even taught to consider, “How is my environment supporting me or perpetuating an issue?” right? If you’re charting in the middle of the emerg, or constantly getting interrupted, or people are constantly at your office, or you have to constantly answer emails, how can we expect you to finish your charting during the day or within the encounter when you’re having nonstop interruptions? So some accommodations could be making sure that you have four walls around you, or that you put up a sign, “Unavailable, charting,” so some kind of external barriers or boundaries, or noise-canceling headphones, right? And it sounds so simple, but it’s actually hard, because most of us don’t do that, right? And sometimes it could be certain software that might help us, like dictation or charting or whatnot.

The other thing that most of us have to do these days is EMR, right? EMR is so complicated. And again, if you really think about it, when I trained, we still had paper charts, right? So I signed, I checked off, I handed it off. If I made a mistake, usually a nurse would come and talk to me and say, “Oh, you forgot this box,” or I would add an addendum or whatever. The nurse would usually be my check-in system.

If you think about it now, with the EMR, depending on what EMR you have, first of all, you have to click. If you don’t click the red box, you might not be able to proceed further, right? So you have to remember the sequence of boxes to order for each order that you might be entering. That in itself is hard. Then you might have to be flipping between different windows to get the information. That in itself, again, is a cognitive task, and it might be really hard for somebody with ADHD, while charting, to stay focused on several windows and retain that information. Because people with ADHD might struggle with working memory, which is kind of like your notepad in the moment, right? So if you’re flipping your notepad between windows, it might be hard for you to retain the information. So it might take much longer to get that note done, and you might be getting distracted and going very far back, looking at the charts and synthesizing. So it takes so much longer than for an average person.

And so again, you see, those are cognitive functions. How long does it take? How long does it take to do this command, that command? An occupational therapist would look at how many clicks you take to do this. How many clicks does this take? What are these things? Because they look at the functional assessment, whereas we don’t stop and think, “Well, it takes me 20 clicks to get to this. It takes me 10 different order sets to actually manage one condition.” And just that simple understanding of what it takes cognitively and functionally for us to accomplish a task or a charting note might make a big difference, because you might come up with a template, or you might come up with some other strategies to help the physician manage all those clicks, or even realize that this is why you’re struggling, instead of “You’re bad, you’re unprofessional, you’re stupid,” because this is the message we get, right? That you’re unprofessional.

So again, that in itself is an issue for charting in ADHD, and that’s where I sometimes use an occupational therapist: to help the physician understand, “What is the cognitive demand of your task? What gets in the way of the cognitive demand? What is the environment around you that either helps you or gets in the way?”

Kevin Pho: Now, in the primary care setting, what kind of red flags or what kind of clues should you look out for in order to refer someone to occupational therapy for a behavioral health condition?

Maryna Mammoliti: So clinically, when would I suggest referring? Let’s say you’re working with somebody through the return-to-work process, or assessing workplace impairment or workplace accommodations. Because even in the U.S., right, there are laws protecting workplace accommodations for people with disabilities and mental health conditions. DSM-5 conditions are considered a disability by most laws.

So let’s say somebody is in the process of returning to work, and you have to do paperwork about what their accommodations are and what their limitations are. It’s probably a good idea to get an assessment by an occupational therapist, whether you request it from the employer or from the insurance company, if there’s an insurance company involved, because they will give you a more objective assessment: “OK, this patient can sit for 20 minutes. This patient can do this for this long.” Now that you have that, you could recommend to the employer what accommodations they need, even physical ones, right? So it’s not just cognitive; it could also be physical, because they do both.

So there’s the return-to-work process, and then when you’re trying to assess level of disability, let’s say how disabled one might be. Sometimes that gets involved in car accidents or other issues. An occupational therapy assessment will go a long way, because they would actually follow the patient in their house. They do the in-home assessment and the work assessment.

The other time is if people are struggling at work or school, because again, an occupational therapist could say, “OK, what’s the struggle? What is the functional assessment?” and whatnot. So sometimes you have kids who are struggling with school, and you have university students who are struggling. They might need that, because occupational therapists, again, can teach organizational skills and other supports for school as well.

The other time is, let’s say somebody wants to come in, because occupational therapists do a lot of occupational coaching. They do values inventories, skills, and stuff. So if somebody comes in and says, “I really don’t know what I want to do with my life. I don’t really know where,” so kind of like career coaching, they can also help with that. So it’s a vast range.

And in certain places, occupational therapists actually do therapy, so they could do cognitive behavioral therapy, and they could do other therapy, depending on what the local regulations are. So sometimes I will refer my patients for therapy, especially when I want my patients to get skills, because occupational therapists are very goal-oriented. Sometimes you’ll hear somebody say, “Oh, I went to therapy. I don’t know what I did. I have no idea.” Well, skills. So if somebody is depressed and you want them to have behavioral activation, or you want them to have skills. I recently referred a patient who doesn’t want to leave the house because they developed agoraphobia during COVID. I referred them to occupational therapy to help this patient slowly be exposed to the outside. I can’t go to the patient’s house. I’m not going to sit with a patient in the car. An occupational therapist will come up with a plan to do some gradual exposure so that they actually can go outside.

Kevin Pho: And my final question: Tell us some of your take-home messages that you want to leave with the KevinMD audience.

Maryna Mammoliti: My big take-home message about this is, one, remember we need to keep up boundaries to sustain our wellness, right? Occupational therapists, aside from being great, amazing colleagues, could actually help you with boundaries by keeping you within your professional boundaries of your knowledge and what you actually know when we’re talking about disability and impairments and assessing your patients.

Two, they could absolutely help us move from a deficit model to a wellness model, because they come up with all sorts of accommodations that we might not be aware of that our patients can use, which could be supported by legal expectations of workplace accommodations, school success, things like that.

Three, they’re really useful for us if we’re struggling at work, if we’re struggling even with sitting. The way we’re sitting, the way our stations are set up: Is that good for your back? Is that good for you? Cognitively, how many patients can you actually work with before you burn out, versus how many you’re stuck dealing with, and you’re burning out, and you’re not going to be available for anybody? So for yourself, how does that help you in terms of your own setup, your practice setup, your physical office setup, your EMR setup, and your sitting arrangement?

And the other thing about occupational therapy and whatnot is that, look, they have a huge range of skill sets, and if you build some relationships with the ones in your area, you will know which ones are available for you. Because our biggest thing is we don’t know. We’re not out there meeting people who are not physicians, and that collaboration goes a long way, because you’ll get to know them.

And I tell people all the time that occupational therapists are evidence-based, regulated professionals. There are lots of coaches out there, and, as I told you, right, I’m a certified coach too. Unfortunately, a lot of the interventions that some coaches use are not evidence-based, and so I have an issue with that a lot with ADHD, because there are lots of ADHD coaches and there’s no regulation. So you could tell somebody, “Go for a run, and it helps you,” and there’s no accountability to that when there’s no evidence for it.

Occupational therapists are regulated health professionals. They have a license. They can only recommend things that are evidence-based. They’re held to a standard, and so their strategies are evidence-based, objective strategies. If you ever have a lawsuit or a board complaint or anything like that, and you relied on an occupational therapy assessment, you relied on an evidence-based assessment to make your decision. You didn’t rely on some random advice on Google. So I think we also forget that, and the service to our patients: When you go to somebody who’s a regulated professional, there is a little bit of that safety and regulation and responsibility. So that is my other thing about that.

Kevin Pho: Maryna, thank you so much for sharing your time and insight. Thanks again for coming back on the show.

Maryna Mammoliti: Thank you.

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