Guest Ryan Laschober, MD, FAAFP, joins guest host Chris Botts, senior manager of care delivery and payment, to discuss the Waco Guide to Psychopharmacology in Primary Care, a resource created to support primary care clinicians’ ability to manage mental and substance use disorders, particularly in rural and underserved communities.
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- Ryan Laschober, MD, FAAFP, residency program director, family medicine, Waco Family Medicine Institute
- Chris Botts, senior manager of care delivery and payment, American Medical Association
Speaker: Hello, and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Botts: Hello and welcome to today’s podcast. I’m Chris Botts, senior manager of care delivery and payment here at the American Medical Association. We are joined by guest Dr. Ryan Laschober, family medicine physician and editor-in-chief of the Waco Guide to Psychopharmacology and Primary Care. Dr. Laschober, thank you so much for joining us today.
Dr. Laschober: Absolutely. Thanks for having me today.
Botts: Why don’t we start with you sharing a little bit more about yourself, your background, with our listeners?
Dr. Laschober: Absolutely. So like Chris shared, I’m a family medicine physician and see patients regularly. I’m also the program director at Waco Family Medicine Residency down in Texas, and the editor-in-chief for the Waco Guide to Psychopharmacology and Primary Care.
Botts: How did the idea for the guide first come about, and why did you and your colleagues feel it was so important to create it?
Dr. Laschober: Absolutely. So at its core, the Waco Guide is a resource to combine top-level evidence, high-impact literature, and expert opinion, all tailored for primary care clinicians. Its real goal is to give primary care clinicians the tools and the scaffolding they need to provide high-quality and efficient care and patient care. It was created free of industry funding by the faculty of Waco Family Medicine Residency in consultation with faculty of Massachusetts General Hospital Psychiatry Academy.
Botts: Excellent. What key specific challenges do you all look to try to help address for primary care physicians?
Dr. Laschober: It’s a great question. So like I shared before, I’m a program director for Waco Family Medicine Residency, we’re the oldest family medicine residency west of Mississippi, and so we’ve had the opportunity to train lots of family medicine physicians. And we look for areas across the health care domain where there may be care gaps that we could enhance and that we could intervene on. And one of those significant areas is we could do better in behavioral health training and behavioral health treatment.
What’s really interesting on the patient side of things is patients prefer, often, to have their behavioral health care by their primary care clinician. And so we looked at many areas in the behavioral health domain and say, “How can we provide better scaffolding and better resources to thrive in the care of behavioral health illnesses?” And the area that rose to the top was the intersection of the highest level of physician-cited discomfort in the highest yields, which is evidence-based psychopharmacology.
A way to think about it is in the world of hypertensive care, we get great hypertensive guidelines now that involve decision supports and are informed by evidence, and we wanted to create the same level of rigor and support the primary care clinicians in the behavioral health setting.
The Waco Guide provides guidance on treating major depressive disorder in adult, to routine treatment of generalized anxiety disorder in a 17-year-old, to much more complicated issues and scenarios that we often see in primary care such as treating post-traumatic stress disorder in a patient with renal failure and a partial response to sertraline who still has residual hyperarousal symptoms.
Botts: It makes total sense. I think many folks know that the majority of these types of treatments actually arise in the primary care setting and many of these medications are provided within that primary care setting, so there’s a huge need for this type of support.
Where did you all even begin? How did you all ensure that such a tool accounted for both a wide range of patient populations, but also the number of comorbidities that happen within these patient populations?
Dr. Laschober: Taking a step back and looking at the behavioral health landscape, there’s a few things that our listeners I think will feel that [they’ll] recognize, but just to articulate for everybody, most patients enter their care for behavioral health illness through primary care, but PCPs often cite being under-prepared or undertrained in psychopharmacology.
Additionally, two out of three PCPs, if they said, “Hey, I’d love to refer my patient to specialty behavioral health services,” could not, they don’t have the access for that, and this care gap is often worse in underserved or in rural communities. When given the choice, patients prefer to be seen by their PCP, and what’s so neat is that evidence and studies have shown that excellent treatment outcomes can occur when that right scaffolding is in place.
And so when we started looking to say, how do we do this well in the primary care setting? We looked at three things. We wanted to combine that top clinical guidelines, high-impact literature, have that informed by specialist opinion, but it really needs to be articulated for primary care settings, and so really combine all three of those things in a usable format.
The one interesting thing, though, is most patients in a primary care setting don’t exist in a single diagnosis. Comorbidity is the rule, not the exception. And so we really needed to lean in early on to say, how do we account for these comorbidities? That’s where we really started bringing in recognition of special populations. So the Waco Guide will provide guidance for the range of ages—so pediatric, adolescent, adult, geriatric ages—but also different special populations that somebody may enter in their lifespan. So when people are pregnant, preconception counseling, or in the postnatal period, for renal failure, or for cardiac impairment, anhepatic impairment, and lastly, in geriatric and obesity populations.
Botts: One thing we hear often as physicians and other care team members, going to separate systems is something they’re usually pretty hesitant to do unless they see such a huge benefit of doing so. It’s like, “Oh, great, yet another site that I have to go to.” But once they started using it, they realized that truly is just adding this one additional thing, especially at point of care, can make huge differences in discussions of treatment options with those patients.
Dr. Laschober: Absolutely. I think if I were the audience right now, I’d be feeling an ounce of skepticism. As clinicians, we’re all trained skeptics, that’s good, that’s healthy. And so hopefully I can walk through the methodology a little bit, peel back the curtain of why this is important, and how these tools can be trusted.
So first, when a tool’s created, our team here, which consists of two family medicine physicians, a clinical psychologist and a psychiatrist, review the top clinical guidelines and high-impact literature, summarize those with a primary care lens. Then we sit down with not one but two experts in their field at Massachusetts General Hospital Psychiatry Academy, these are often the most published experts in their field, to sit down and agree upon a shared decision support tool.
And that’s a feat in itself. To have two experts agree upon one synopsis, one shared synopsis of a treatment protocol, is a feat in itself. And so then this comes back for a final primary care review to know that it can be really used in a primary care setting with that primary care lens.
A great example then in practicality in use is the bipolar decision support tool. When we created the pregnancy bipolar decision support tool, our Massachusetts General Hospital Psychiatry colleagues were just fantastic in the creation of that.
It’s such an impactful tool for treating bipolar disorder and pregnancy, which just really limits some of our pharmacotherapy options at times. And the feedback has been phenomenal. I can tell you a conversation I had about six to 12 months ago with an OB-GYN, who previously was cautious about treating anyone with bipolar disorder in pregnancy because she didn’t have the tools and the scaffolding and support to know she could succeed and her comment to me was, “Wow, I now have the tools I need to move the needle for this patient’s life.”
Botts: Thanks so much. I think that’s a really helpful background and framework of the purpose of the guide, and I think have highlighted some really good value points of what it’s really trying to accomplish. Can you maybe walk us through how a PCP might use the guide in their practice?
Dr. Laschober: So a lot of clinicians feel comfortable with the first one to two treatment steps of many disorders seen in primary care. Where it’s really helpful to have the further guidance is on those next treatment steps of, what if a patient failed first or second line pharmacotherapy, or impartial responses, or what does the true evidence say about augmentation of a partial response of pharmacotherapy?
Additionally, those special population areas can be really helpful as our patients change through their lifespan, the guidance will change as well. So special populations can be really helpful there.
Many of these medications can come with side effects as well. Especially when we think about atypical antipsychotics, there can be a significant side effect burden. And so, one area that we wanted to support primary care clinicians and the patients they care for is atypical antipsychotic side effect management. You’ll find on the Waco Guide, guidance for treating the common side effects that we may see, such as obesity, treating hyperlipidemia, or some of the other movement disorders that may be common with these medications.
Sometimes primary care clinicians struggle with knowing the right evidence-based way to transition from 1 pharmacotherapy to another. What you’ll find on the website and app is medication switching tools. So when I want to transition somebody from citalopram to venlafaxine, you can plug in those two medications and receive an evidence-based guide of how to make that adjustment. Especially too, when we think about atypical antipsychotics and mood stabilizers, you’re able to input those medications and receive an evidence-based recommendation of how to transition from one medication to another as well.
This is really meant to be a point-of-care tool to help make informed treatment decisions even in the exam room. And so clinicians can access the Waco Guide through multiple ways, via a website, or an iOS, an Android app. And when you interact with the guide there, you’ll see two options of how to use it. One is a question-and-answer feedback option that helps guide you through treatment steps, ask questions, ask prior medication trials, to make an informed but individualized treatment decision.
Users find that usually takes about 30 to 60 seconds to input that information to get an informed treatment decision about their patient. We really want this to be a usable point-of-care format option. There’s little use in having an option that takes minutes upon minutes to be utilized because that can’t really be used at the point of care then, and so that quick access is crucial.
Second, clinicians can see that the decision support tools in a top-down approach, they can see the whole pathway, we call that our comprehensive view, and that can be a really useful tool as well. What we found interesting too is that comprehensive view, our patients really enjoy that. Especially in behavioral health illnesses, patients often can feel that guinea pig phenomenon. Their clinician is just trying medications on them to try to see what works.
When you look at a decision support tool then with a patient, it creates a common roadmap and a common language where the patient can now acknowledge and see together, through shared decision-making, that there’s step one. And if that’s unsuccessful, there’s a next step. And that next step accounts for contingencies, it accounts for partial responses, and successful responses. Obviously the ultimate goal is successful response as well.
Botts: And what’s the reception been by PCPs so far? Any feedback in particular about the potential impact on patient care?
Dr. Laschober: So we are a 60,000 patient, federally qualified health center, Waco, Texas, provide great care for Central Texas here, and we knew the Waco Guide would have an impact for our community.
What we maybe didn’t fully anticipate is the level of engagement and excitement we’d see across the nation. So now we have over 50,000 individual website users, over 11,000 app downloads across the nation. But really what matters most is seeing patients’ lives being changed, hearing feedback from PCPs that they feel confident, especially in those complex, but also routine behavioral-health disorders. And so that’s the thing that really moves the needle I think most for us, is seeing those lives and hearing about those lives being changed.
Botts: It’s amazing to hear about the true impact of something going from identifying the need to actually putting it out there and making a difference, especially for patients, because that’s ultimately what PCPs and their care teams are really trying to strive for.
Given how robust the tool is, as we’ve discussed a little bit, how often is the guide reviewed and updated, especially given the number of patient populations and comorbidities that you all are trying to accomplish with the guide?
Dr. Laschober: Great question. The short answer is it’s updated as often as high-impact literature and guidelines change, the Waco Guide changes as well. Formally, we sit down with our faculty at Massachusetts General Hospital Psychiatry Academy every two weeks to review two things. One, any significant updates in the psychiatric literature and the behavioral health literature that should adjust the decision support tools. And then two, we sit down and review, at minimum, every two years a full top-to-bottom review of every decision support tool. And so they’re on a reoccurring cycle there where we review any other literature, any other unique applications, especially in the primary care setting.
And then the last thing is, at its core, I’m a practicing family medicine physician, and we really appreciate the real-time feedback of conversations with clinicians that then when they share feedback, it comes directly to our team that creates the Waco Guide. And so we’re able to review studies through real-time feedback of other practicing clinicians as well.
Botts: And I am sure the users also appreciate both that ability for feedback as well as just all the effort that you outline to ensure that the guide stays updated, given again how robust it truly is.
So how would PCPs use the specific guide? Do they typically use it in the exam room while the patients are there? Is it something they reference afterwards as they’re working out the notes and figuring out what the next steps are for treatment? How do you all envision and how should PCPs look to utilize the guide within their practice?
Dr. Laschober: That’s a great question. So really we view this as a point-of-care tool, meaning it can be utilized in the exam room or outside, whatever works best for your patient flow. Patients have shared with us through their feedback that they’re really receptive to their clinician, utilize it in the exam room. We can ask patients then, right then and there, what their prior pharmacotherapy trials looked like and give that informed treatment decision right there. And so we see a lot of folks use it right in the exam room. And actually, patients really are receptive and prefer that sometimes as well.
Botts: Lastly, any practical tips or pearls of wisdom for other health care leaders who may be interested in implementing this resource in their practice?
Dr. Laschober: I think we get the opportunity to interact with lots of groups, and there’s a couple feelings, both the acknowledgment, this is crucial to my patients’ care, but there’s also a level of intimidation at times of, I was undertrained in residency for this. We hear that a lot from folks. What I want to encourage folks is your patients want you to do this, they need you to do this, and with the right scaffolding in place, you can thrive in this care.
I think where the Waco Guide can be really helpful in folks’ practice is bring in the guidelines and expert opinion all tailored for primary care to them. It allows them to be the physician again, where now we get to sit with the patient, discuss, advise, recommend, give anticipatory guidance, talk through side effects, all those things that no computer can do, that we as clinicians thrive in most. It really gives us the resources to make those informed decisions to then thrive as the clinician in the exam room.
Botts: That sounds fantastic, Dr. Laschober. Can you let our listeners know how they can access the guide?
Dr. Laschober: So in its current form, it’s freely available at a website, Android and iOS app, as well as soon to be, will be available for a nominal fee in the Amazon bookstore. The website is wacoguide.org or wacoguide.com, both will take you there. And then Waco Guide - Psychopharmacology, if you search that in both the iOS or Android app stores, it’ll go there.
And then there’s book form that will be available soon on Amazon. And the cost of that just goes to the printing side of things, so still we view it as a free resource there.
Botts: Excellent. Well, thank you so much again for joining us today, Dr. Laschober. It’s always a thrill to discuss y’all’s fantastic work.
Dr. Laschober: Thanks for having me. Really appreciate it.
Botts: And for those in our audience that are interested in learning more about how to use tools like the Waco Guide and other practical solutions within integrated care primary care settings, please visit the AMA’s website, searching behavioral health integration, for a number of specific tools and resources to help you and your practice better support your patients and their overall whole-person care.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA's STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.