What is my approach to starting CBT-I in family practice? I want to know if it works. Further, I want to know if my Canadianized version is effective. Canadianization? A new word perhaps. Two hour counselling sessions don’t fly in family practice. At least north of the border. You need a bare-bones, more punchy but still supportive approach.
If you haven’t read my prior post, please do. And visit www.cbtforinsomnia.com. (Gregg Jacobs)
How do I set up my qualitative study, realizing that I’ll only have 10-20 patients a year, not 25000? How do I manipulate the described course for my own patients? How do I make it work in my practice? How much material do I need to include, and what can I cut out?
Look at some basic principles of initiating a qualitative study in your practice:
- Fully understand the new intervention. Read, and read supportive materials.
- Look at where you’re practicing, the population you have, who you are, and compare this situation with what you’ve read. If it’s not the same, and it never is, you’ve got to make some intelligent jiggers.
- Do a search of your patient database, and try to find candidates for the intervention.
- Send letters to these patients outlining the new intervention, and suggesting an appointment.
- Ensure staff realize how to book the appropriate appointments, allowing you enough time to start the new intervention.
- Have printed materials ready.
- Produce a stamp, or template within your EMR to stay on track.
- During the initial interview, take a good history around the symptom or condition, and attempt to get a measurement of severity. This could be as simple as a Likkert scale, with the patient judging severity on a scale of 0-10. Depending on what you’re measuring, you could use several scales: one for severity of the symptom, one for the degree of disruption of life at home, or work, or school, or social life, or one each.
- Impose the intervention.
- During the imposition of the maneuver, you will find that you change your approach. It happens to everyone. A qualitative study is not a closed box you observe from a distance. You’re in that box, that Skinner box, with the patient. YOU. You won’t finish doing your study the same way you started. No one does. Just document the changes.
- Get an outcome score at the end.
- Think you’re finished? Look where you are, where you started, look at the intervention, the documentation of changes, see if things improved, and see what you can do to further improve the outcome. You may need to do some more ancillary reading, or meeting with colleagues.
- Then you do it again, with your polished up, tuned up, intervention!
That’s the thing. Once you start doing this, you never really stop. You can become less formal, but this is an approach that changes how you practice. You may have several things going at once!
In regards the CBT-I, and my progress thus far, what have I found?
A number of things have already popped out of this little study. Some findings. To start with the most embarrassing, I’d like to share with you the number of charts where I had insomnia listed as a problem. A computer search of my EMR found only NINE patients (I have a practice of about 2500) that had a diagnosis of insomnia AND a drug used to treat it. There were no patients that had insomnia listed that did not have a sedative listed, despite the clear fact that CBT-I beats sedatives on head to head trials, and is the most indicated treatment. A further search on “insomnia OR drug” turned up 456. Drugs searched for included some typical psychiatric medications. Right there, that changed my approach to practice. The diagnosis of insomnia made a more frequent appearance on problem lists from then on.
Dr Jacobs’ 2 hour session approach simply is not tenable in Canada, and certainly not in my clinic. At Harvard, apparently he would do large groups and the occasional one on one. I would not come close to thinking of billing a 2 hour therapy session with anyone for anything, sure that it would bring down the hounds of OHIP audit hell on my heels, or worse, on my neck. And, with the current FHO setup, there is almost no large space where I could run a group if I wanted to: clinics run morning to mid evening, and I would have to use the waiting room. Not available.
So, pretty clearly, decisions were made to do only one on one sessions, and to limit the interview to a normal counselling visit, which is 20-30 minutes, 50 at a push.
Now, how do you get 2 hours down to 20-30? The way I make 50’s happen, honestly, is to try not to do them, and just push into the next patient visit. Which increases my gastric acidity. And everybody else’s.
Another principle for me to keep in mind is to remember the differences between my clinical setup, and Dr Jacobs. There are strengths, and weaknesses. Yes, OHIP certainly wouldn’t enthusiastically pony up two hour consultation/ therapy fees. But I was their family physician (often for a lifetime!), which was an advantage. Where Dr Jacobs had to bolster his position with review of literature, I could afford to just share the pearl, and tell the patient that solid literature existed to back this up. That worked. With a long term relationship, sometimes that’s all you need. There’s a time savings!
Going one on one, you didn’t need to deal with the intergroup chatter, and interpersonal dynamics. More time savings. Yes, that probably helps if you have that luxury of time. Us Canucks don’t.
I fairly slavishly stuck to the abbreviated outline I worked up, trying to stay as much on tack as possible. My office manager helped me make a specific stamp for each visit. Basically, I just had to do it, point by point. It kept me on track, and helped me stay organized. I warned patients at the outset that this was more like a seminar, one in which they were the student, and I the teacher. I shared that I was willing to hear them, of course, but there was a lot of material to go over.
They accepted that. They knew I was trying to help them, to bash a 2 hour session into a shorter one. They knew that this was an addition to my already busy practice. Would this work elsewhere, with someone else? If I was a newer family MD? If I was urban? Don’t know. But it worked, and is working (for I’m still doing this study) for me.
What have I changed during the intervention imposition?
I’ve just brought in a formal Likert scale at the beginning orientation/ history taking visit. I had been documenting the history, and the degree of distress, but that was clearly subjective, in my head, which means nothing. I need to take a measurement of how awful they felt.
And an overall Likert scale at the end.
Those of you familiar with Dr Jacobs program (www.cbtforinsomnia.com) realize that an important part of the visit is the calculation of sleep efficiency. Not enough. Not enough for me, to really measure that smile after the last appointment.
Because that’s what happened; what is happening. People were, are, happy both doing this course, demonstrating substantial relief during and after the course. Yes, you can look at improvements in sleep efficiency, but that doesn’t really catch the smile, the twinkle in the eye.
Several people have opted for doing the online course for patients that Dr Jacobs offers. I need to find some way of capturing those people, and see their completion rate, success rate. I’m still chewing on that one.
Look at Jacobs’ site.