Many visits to primary health care physicians are related to psychosocial problems. Physicians often treat these problems themselves and rarely refer patients to mental health professionals (Jones, Badger, Ficken, Leeper, & Anderson, 1987; Regier et al., 1993; Schurman, Kramer, & Mitchell, 1985; Zimmerman & Wienckowski, 1991). Some have called primary health care physicians the "de facto mental health care system" [italics added] (Regier et al., 1993, p. 85). In social services and mental health settings, social workers are most frequently the ones who care for psychosocial problems. In the United States, the locus of care for many psychosocial problems can be expected to shift to primary health care settings as health care reform moves toward integrating mental health into the general health care system. Such a system, as has recently been outlined by Mechanic (1994), will increase the likelihood that people will receive the most appropriate form of care. In such an integrated system, the primary health care physician would serve as a gatekeeper for other, nonmedical services. Even now, the move toward managed care and care centered around health maintenance organizations (HMOs) presents social workers with opportunities and challenges.
The literature suggests that primary health care physicians need the special knowledge and skills that social workers and other mental health professionals can contribute. Despite the substantial role that primary health care physicians play in treating psychosocial disorders, there is evidence that they often fail to identify and treat mental health problems in general (Sartorius et al., 1993) and substance abuse in particular (Milhorn, 1988). Social work intervention could be an asset in primary care settings; moreover, it has been shown that interventions reduce the utilization of medical care (Jones & Vischi, 1979; Kiesler, Cummings, & VandenBos, 1979; Mumford, Schlesinger, & Glass, 1982; Schlesinger, Mumford, Glass, Patrick, & Sharfstein, 1983). Social workers could help physicians by teaching them psychosocial skills (Zayas & Dyche, 1992).
Yet, to date, social workers have struggled to define their role in the primary health care setting (Greene, Kruse, & Arthurs, 1985; Gross & Gross, 1987b; Gross, Gross, & Eisenstein-Naveh, 1983) owing to inherent strain between the professions due to differences in values relating to patient care, such as saving life versus quality of life, and differing views on patient autonomy and the role of the health care professional (Abramson & Mizrahi, 1986; Mizrahi & Abramson, 1985; Roberts, 1989). The work done on social worker and primary care physician collaborations suggests that younger physicians have more positive attitudes toward social work interventions (Gross & Gross, 1987a). In view of the changes in the health care system and the vital need for social workers in an integrated system of health care, social workers should consider their role in primary health care settings and vis-a-vis primary health care physicians.
This article discusses the extent to which primary care physicians act as gatekeepers for psychosocial problems and the extent of their contact with social workers. Given that almost all health care in Israel is provided by HMOs, the situation in Israel, where this study was conducted, may be instructive for professionals in the United States and other countries, where health care is increasingly being based on HMOs. In Israel most health care is provided by one large HMO run by the national labor union and heavily subsidized by the government. The predominance of care is provided by salaried physicians. In the smaller HMOs the predominance of care is provided by independent physician practitioners. Most social workers are employees of the HMOs. Their primary role is to deal with patients who present psychosocial problems. Although patients can seek out social work assistance, patients are typically referred to social workers after reaching an impasse with the health care system. …