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Join us on this episode as we speak with Hilary M. Bowers, a pediatrician who shares with us the importance of integrating behavioral and mental health care within primary care practices. With one in five children and adolescents receiving a behavioral or mental health diagnosis by age 18, and with youth depressive symptoms doubling since the onset of the COVID-19 pandemic, it is crucial to provide the right care at the right time to the right patient.

Hilary discusses how her organization successfully integrated mental health care into their pediatric medical group, which cares for approximately 270,000 patients from birth to 21 years of age. She emphasizes the need to identify a champion and form a network of partners within the community-based organizations. Hilary also highlights the importance of supporting open communication and providing ongoing education to clinicians to provide evidence-based care.

As parents and guardians look to us for guidance on various topics, including behavioral and mental health issues, we need to be there to provide the best care possible for the whole child. Tune in to this episode to learn more about how you can integrate behavioral and mental health care into your primary care practice.

Hilary M. Bowers is a pediatrician.

She shares her story and discusses her KevinMD article, “Changing the pediatric care landscape: Integrating behavioral and mental health care.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Get CME for this episode by clicking on the CME link in the show notes. Today we welcome Hilary Bowers. She’s a pediatrician. Her KevinMD article is titled “Changing the pediatric care landscape: integrating behavioral and mental health care.” Hilary, welcome to the show.

Hilary M. Bowers: Thank you so much for having me on. I really appreciate it.

Kevin Pho: So we’ll get into your article in a little bit. First off, briefly share your story and journey to where you are today.

Hilary M. Bowers: Yeah, so I am a general pediatrician by training. I have lived all over the country: I grew up in the Midwest, then the East Coast, the West Coast, and currently I am based down in San Diego, California, with Children’s Primary Care Medical Group. I’m currently the director of behavioral and mental health services for our organization. We have the second-largest single-specialty pediatric group in the country, so there are quite a few patient lives that we’re touching, which I really appreciate.

Kevin Pho: So tell us some of the challenges and rewards of practicing pediatrics in today’s health care landscape.

Hilary M. Bowers: So obviously there are reimbursement issues, there are time issues, and we’ve had a pandemic. I think maybe you’ve been living through that as well. But I think one of the biggest things in pediatrics is that when you walk into the room as a pediatrician, you don’t have just one client, right? You have your patient, but then you also have the parent, the caregiver, the aunts, the siblings, whoever else is also in the room with that patient. Whoever else lives at home with that patient is part of your care team. And you’re trying to convince not only a five-year-old of what you would like them to do, but also the parent of the five-year-old, because obviously the five-year-old’s not driving to the store to do the grocery shopping.

Kevin Pho: So you mentioned the pandemic, and of course there’s that intersection between the pandemic, pediatrics, and behavioral health. Tell us what you’re seeing in the exam room today as it relates to that.

Hilary M. Bowers: So currently we’re seeing a significant increase in behavioral mental health concerns. I think one of the biggest shifts that we’ve seen with the pandemic is that these concerns were always there. Even pre-pandemic, one in five children would be diagnosed with some behavioral mental health diagnosis by the age of 18. What we’ve seen since the pandemic is that a third of our adolescent girls are depressed, and one in seven males are contemplating suicide. Males in general tend not to talk about it.

So that whole thing as a pediatrician is: How do you create that relationship with your patient so they trust you, they’re willing to confide in you, they’re willing to recognize that they are having challenges and that you are a source of support for them? I think that is so very important. Out of the ACEs studies, looking at childhood traumas and also looking at the resiliency factors, one of the major resiliency factors is having one trusted adult in your life. Having that somebody who sees you, somebody who is showing up for you and expects you to do amazing things in your life, then allows you, regardless of what you may be experiencing at home or at school or personally, to go ahead and move forward and achieve those goals. So you as the pediatrician can be that trusted adult.

Kevin Pho: All right, you talk more about that in your KevinMD article, “Changing the pediatric care landscape: integrating behavioral and mental health care.” Tell us, how did this article come together?

Hilary M. Bowers: So I’m going to take you in the time machine. We’re going to go back to 2015. I had one of those aha moments with a patient who literally sat down, pointed a finger at me, and said, “Why can’t you take care of my patient? Why can’t you take care of my child?” They had to go see a psychiatrist to get their medication. I have very many psychiatry colleagues whom I love, but their particular experience was that it wasn’t the satisfying, relationship-based care that we think about in pediatrics. And I said, “Well, why not?” So I presented to our leadership at that time and said we need to bring behavioral mental health back into the primary care home. How can we harness our pediatricians’ knowledge and really deploy it across our organization?

Fast-forward many years later, we have educated across our organization in what I consider the big three: ADHD, anxiety, and depression. How do we diagnose it, how do we treat it, and how do we talk to families about it? And then also, some of our offices do have integrated health therapists located there, so that way we can have more immediate access to that therapeutic service that we know is so important. Medication is just one of the tools in our toolkit, and we know for sure that having that therapeutic piece, doing that behavioral modification, is key.

So the KevinMD article comes out of my desire to make sure that everybody has access to this knowledge. This is something that we did in our organization, but smaller groups can do this as well. And how do we pivot and make sure that we’re providing the care that our patients need at the correct time?

Kevin Pho: So give us a before-and-after picture. Before this intervention, what would it be like for a child and their family with one of the big three, ADHD, anxiety, and depression, coming to your office, and then after the intervention?

Hilary M. Bowers: So before, a family would call in and say, “I think my child is struggling with inattention,” or depressed mood, and sometimes our pediatricians wouldn’t even bring them in to have a conversation. They would say, “OK, you need to go see a psychiatrist,” or “Go find a therapist.” Or if they did bring them in, sometimes it would be a kid who was missing a lot of school, or had chronic headaches or belly pain, and the child would end up being sent to GI for a workup, and now the kid’s having tests and scopes and things. In the end, it may have turned out that it was the anxiety talking and bringing on these physical symptoms, but it would have been a very expensive, very costly, and time-consuming workup. That was the before.

Now what we have is our pediatricians who are willing to have the conversation with the families. They come in, just like if you have someone coming in and saying, “I’m concerned my kid may have a broken leg,” or “My kid may have an ear infection,” or diabetes. “I’m concerned my kid has attention concerns.” Same thing. Just like we learned back in medical school, the history and physical rules everything. So have the family come in, you sit down, you have a conversation with them, and then you’re able to make a much more informed decision about what the care plan needs to be.

I will say, Kevin, one of the things I’ve noticed in this area of medicine is that there is so much forgiveness from the families. It’s really one of the only times where I’ve had maybe a 30- or 60-minute conversation with a family, and at the end of the conversation, the entire plan is, “I’m going to go call my psychiatry colleagues. I’m going to call my therapy colleagues. We’re going to come up with a plan. I’m going to call you back in a week.” And the families are ecstatic. They are so happy that somebody took the time to listen and that you’re going to join them on the journey to wellness for their child. So it’s really quite rewarding.

Kevin Pho: So tell us about the education itself. What kind of training did you implement among your clinical staff?

Hilary M. Bowers: So we actually partnered with the REACH Institute, which is a nonprofit organization, and it starts with the PPP training. So it’s a psychopharmacology, I always mess up the title, the PPP training through the REACH Institute. It’s a three-day workshop, Friday, Saturday, Sunday, so you’re not missing a lot of time, and they actually do quite a bit of it online. They shifted online due to the pandemic. It’s Friday, Saturday, Sunday education on ADHD, anxiety, and depression, as well as a little bit on bipolar disorder, atypical antipsychotics, and things like that. There’s role-play involved with that, and there are small groups. It is led by master child and adolescent psychiatrists and master pediatricians.

And that is followed by six months of every-other-week, one-hour, case-based presentations. So one of the pediatricians in the group, and again, this is proctored by a child and adolescent psychiatrist and a pediatrician from the REACH Institute, does that 5- to 10-minute presentation, and then you have the rest of the hour to discuss and come up with a plan of care. What else came up? How do I then take that to my other patients in clinic? So it really solidifies the knowledge.

As you may imagine, some physicians really lean into this kind of work and some do not, and we definitely had some people who did not. They were like, “I’m doing this because I have to, not necessarily because I want to.” So that was Friday. Monday, they emailed us and said, “That was the best CME I ever had.” And Monday, they felt that they had the tools to be able to at least have the conversation with the families, to be a little more in that slightly less uncomfortable position of feeling like they had that knowledge.

One of the other key things that we’ve been doing for education purposes is to say this is a little different than some areas of medicine, right? A kid comes in with an ear infection, they give them an antibiotic, they get better in 48 hours, and they’re moving on with their day, right? So there’s a challenge, and there’s a cure. Here, there’s a challenge, but the road to wellness may take a little bit longer. And we’re teaching all of our clinicians, because we have pediatricians, we have NPs, and we have PAs in our organization, teaching them all to be a little more comfortable in the unknown. And that is a challenge, right? That’s a challenge for us as practitioners, to be able to say, “I’m going to take the journey with you. I don’t know exactly how long it’s going to take.”

Kevin Pho: So tell us, in terms of general pediatric training, aside from having this CME from the REACH Institute, what kind of training do most pediatricians have when it comes to some of these behavioral health issues?

Hilary M. Bowers: So most pediatricians have a month of developmental behavioral pediatrics. Yeah, that kind of varies depending upon what organization you’re at, and if you’ve been in practice for a few decades, you may not have even had that training. There are some places where maybe you do two weeks with child and adolescent psychiatry, but it’s just not. Most of pediatric training is still very hospital-based, right? There’s lots of time in the NICU, there’s lots of time in the ICU and on the wards, and not as much time out in general community pediatrics.

Kevin Pho: So if you wanted to spread this program to other pediatric programs and other pediatricians across the country, tell us what the next steps would be.

Hilary M. Bowers: I think one of the key things is identifying a champion within your organization, somebody who says, “I will take the lead. I’m going to do a little research. I’m going to be the one.” Maybe they serve as an internal referral for the organization. So that’s what I did at the beginning. I was serving as an internal referral. My general pediatrician colleagues would refer a patient to me, and then they could get in a lot faster than in our community. So having a champion is key.

Ongoing education: making sure that everybody has the same knowledge base, the same language. Because we’ve all gone through this training together, we all have a common language we can speak now, and it’s not just medicalese. And then the ongoing education piece is key, so not just that six-month follow-up; we have ongoing talks every other week, very short, case-based, on Zoom, so nobody’s driving, which is key. We have that so that it’s continuing to be at the forefront of our minds as pediatricians: “Yes, we can have these conversations. Yes, oh, right, I was doing that. Yep, still the right thing to do.” So I think that’s really important, to have that ongoing education piece.

Another thing that we’re doing is that the associate director of behavioral mental health services and I are doing road shows. So we are going out to the individual offices. We have a questionnaire, several questions that we ask before we go, to identify sticking points as to maybe why they’re having challenges, and then we come with very concrete ways to say, “OK, let’s do these two new things. Let’s see how it goes. We’ll check back in with you.” So like any other organization trying to make a change, you make a little bit, you check back in, and you do it again.

Kevin Pho: We’re talking to Hilary Bowers. She’s a pediatrician. Her KevinMD article is titled “Changing the pediatric care landscape: integrating behavioral and mental health care.” Hilary, tell us some of your take-home messages that you want to leave with the KevinMD audience.

Hilary M. Bowers: I think the key is you can do it, right? I think a lot of people are afraid of change, and remember, our patients are afraid of change as well. We are all human. But you can do it. Start with one patient. Say, “Here’s a patient of mine that I’ve known for years. I see that they’re struggling. I’m going to give them the PHQ for depression, or the SCARED for anxiety, or the Vanderbilt for ADHD. We’re going to try it.” Identify support, either within your organization or within the community. Develop a relationship with some child and adolescent psychiatrists. I have found that they are amazingly receptive. They are also overwhelmed, so if you can work together as a team, that’s great. So take that initial step, maintain your personal support network, and go out and try. Honest, open communication with your organization and also with your patients will get you very far.

Kevin Pho: Hilary, thank you so much for sharing your time and insight, and thanks again for being on the show.

Hilary M. Bowers: Thank you so much for having me. I really appreciate it. Take care.