1 Boring Old Man

This is interesting. I am that psychiatrist. I work primarily with people who have experienced psychosis – with or without accompanying mood symptoms. Many of them are prescribed drugs and I see it as my role to understand the full differential diagnosis and then then offer the drugs in a considered and informed manner. Since almost all of my patients are poor, their treatment will invariably be paid for by the government and I think it is reasonable to want to do that in a humane, cost effective manner. I do not think those things are mutually exclusive. But I do not do this alone. I work along side a large staff who have talents and abilities that hopefully compliment mine. When I am not feeling demoralized by the many problems of our profession, I am actually proud of the work we do as a team. I am especially proud of my colleagues and most proud of the heroic souls who cross the threshold of my office daily seeking help.
What I was trying to address is what exactly the medical people in this area of the universe can do. I happen to think that for historical reasons the label “psychiatrist” is confusing and misleading. It is not so much that neurologists, as they are currently defined, take on this work. I realize I did not state this clearly but that is a more concrete interpretation of what I was trying to say. It was more about defining what I think medicine has to offer and the role I think medicine, per se, has to play in approaching the needs of people who experience these extreme states.
I have no doubt that you were and are a wonderful healer in all senses of the word. I do not think you are the only gifted MD/therapist. This is not meant as an attack on you or any of them. It is more about resources and the future. I ask this with respect and curiosity, what aspect of your medical training helped you to become a therapist? Is this the best training for that profession? Is it worth the cost?

I understand the wise use of money. However, the push for cost-containment usually falls on deaf ears with me after seeing that whatever is saved mostly ends up in an executive’s pocket or that it brings little taxpayer relief or both.

Random observation: There are experienced nurses that I would want to take care of me in the ICU before some of the physicians that rotated through hospital coverage. Yet, I’d take the experienced cardiologists over either.

Some more uninformed questions from me, but that’s why I ask. Why aren’t the demands of the clinical situation defining the skill set necessary? And, the skill set of the provider defining their worth? How to obtain and pay for these skill sets, I don’t know, but I am curious to know the thoughts of those with greater insight/knowledge of these things than I.

Arby,
I think we are seeing something of a two branched system. Those in the public sector get the kind of care I describe. Those in the private sector and living in certain regions can choose to get a different kind of care. There is an issue of training, though,. When we talk about non-pharmacologic treatments, we are really talking about a vast array of things. I am just not sure how you fit that into a training program without risking having everything watered down.

One other point, the care I describe is not inherently lacking in humanism and empathy.

Arby,

You comments on skill set are right on the mark. Skill set and the analysis of information is really not considered by insurance companies. The other key problem is allowing business practices to define a profession. Where else does that occur? I would suggest that refuses to accept insurance protects the integrity of the profession.

http://real-psychiatry.blogspot.com/2014/05/blaming-psychiatrists-for-decreased.html

What’s even financially smarter than taking insurance only?

Quitting medicine and joining the cronies who are destroying the health care system…

http://blogs.marketwatch.com/health-exchange/2014/01/15/brokerage-says-pro-obamacare-stocks-are-up-533-in-the-past-year/

They have a lot of nerve blaming this on psychiatrists who have figured out a way to reconcile ethics and economic reality.

“I ask this with respect and curiosity, what aspect of your medical training helped you to become a therapist?” Taking care of sick people.
“Is this the best training for that profession?” It was for me.
“Is it worth the cost?” It was to me.

Those aren’t facetious answers. It’s just what I think. If physician psychiatrists cost too much, don’t hire them. Hire some other kind of physicians [though pay-wise, psychiatrists often bring up the rear]. If it is to control over-medication, don’t hire physicians who sign up for Managed Care panels. Managed Care created the kind of physician psychiatrists you [and I] want to get rid of. And don’t hire non-psychiatrist physicians because they prescribe more than psychiatrists do. The majority of patients who see overprescribing physician psychiatrists are referred to them by their Managed Care plan or non-physician mental health types.

Your suggestion to train psychiatrists or some other kind of physician less, just to focus only on medicines, seems backwards to me. The resulting psychopharmacology specialist is hardly less likely to prescribe than someone more broadly trained. But, as I said, I don’t really want to debate the fate of psychiatry because in that debate, psychiatry will be defined as the subset of psychiatrists who have already become psychopharmacology specialists. And I have no more interest in perpetuating that than you do.

Here’s an alleged adage that I think has true traction these days:

“You are what you treat.”

So, if that has merit, if all you do day in and out is see 20 or more patients a day and just write prescriptions and then more prescriptions for WHEN the patient is not better and yet not reinforcing a multifactorial approach to care, what are you by so many months?

A pez dispenser

And patients almost may rotely just walk in and open their mouths to just swallow a pill. So, when you have learned a profession that has taught you honest and efficacious interventions that aren’t just about writing for the “right”pills, and are told by numerous alleged supervisory sources that is all you can do is prescribe, prescribe, prescribe, what does that go on to make you further when you listen to that rhetoric?

A robot.

Now, you true to fight the system and educate any and all who want to hear a viable and responsible truth that the intervention you are forced to sell is not appropriate nor effectively efficacious , and everyone just rejects you and tells you not only you are wrong, but you have to follow the path that is laid out before you and can’t deviate at all. What are you now, again, if you are what you treat?

A lemming.

The final straw is what are you when your own colleagues who you trained with about the same time all tell you that you can’t do anything to really change the system, that in fact “that’s just the way it is, some things will never change”, and they just repeat it like the morning Pledge of Allegiance?

A whore, or a coward, even both?

So, if you are where I am now today, if you succumb to being what you treat and who you surround yourself for professional support and direction, what are you?

A robotic cowardly and whoring pez dispenser who is running to the cliff as a lemming and preparing to thrust oneself off a cliff.

Did you see that ending coming, figuratively or literally?

Sorry for a spelling mistake and better wording at the end:

after “A robot” the next sentence should start with “Now you TRY to fight the system…”

and at the end the next to last paragraph should have ended with “…preparing to thrust oneself off THAT cliff.”

You probably could have figured that out, but I want the comment to be as sensible and coherent as a robotic lemming crazoid can make it!

Let’s get real. Psychiatry Residency Training programs– for the most part– have abandoned psychotherapy training for the past 25 years. If you want therapy from a psychiatrist, you will have to find someone over 60 years old.

PS: I said “for the most part.” There are exceptions, but not many.

Dr. Steingard,

Thanks for your response. My rudimentary questions were a way to try and make sense of the disconnect between clinical needs and budgets. To me, they are largely caused by the misallocation of resources by those in government and/or micro-managed care at this point. Also, it doesn’t surprise me that there are two types of care. Perhaps more. Last year something Dr Moffitt wrote in reply to me clued me onto what Greyhound Therapy is. How unconscionable, yet in a twisted way it makes perfect business sense, except of course for the getting caught with all the bad press part.

I apologize for going off topic, yet the thought of what you are given to work with, and what Dr. Dawson wrote in his article he linked to here, made me think of all of this.

Dr. Hassman,

If you take the doctor/patient and prescribing element out of your scenario, that fairly accurately describes the dynamics that occur in Corporate America on a daily basis, and explains why the Dilbert comic strip had such success.

@ Sandra

With all due respect, I bring all of my medical training into my practice of psychotherapy. Knowing anatomy helps me teach people how to breathe using their diaphragm, when they are struggling with inaccurate advice from well-meaning but ignorant non-medical therapists; knowing the way immunomodulators can affect mood has helped me explain to some of my patients why they feel depressed every time they are fighting off a URI, and that they don’t need antidepressants but rather rest, Tylenol and chicken soup; understanding shoulder and cervical musculature has helped me teach patients with “migraine” headaches how to reduce their neck tension and stop their migraines; knowing the dynamics of the stress response system has helped me create extinction protocols for my patients who have PTSD.

I could go on and on, but to me the practice of psychotherapy is deepened and made far more effective by integrating it with medical training and experience. I see psychotherapy as very much like applied psychoneuroendocrinology. I track beat-by-beat heart rate while working with most of my patients and by watching the way their heart rate variability changes in real time I can adjust the timing and the intensity of my interventions. The literature on memory consolidation and reconsolidation, the research on neuropeptides associated with various types of stress, the articles on heart rate variability and autonomic response are all relevant to psychotherapy and very few non-medical therapists can understand them.

When I wasn’t so busy I used to give workshops for therapists on how to understand the autonomic nervous system and its relationship to psychotherapy and those were very well received. A lot of therapists wish they had this kind of knowledge. It is a tragedy that there are not more physicians who know both the body and the psyche.

Your proposed solution would only make this worse.

Dr. Dawson,

Thanks for the reply. I liked your perspective, yet the fact that you had to close your clinic was very disturbing. For some strange reason, it reminded me of the first thing I learned about hospital budgets. Our Pharmacy Director used to come back from budget meetings looking worse for wear. One day I asked him about how it was going and he told me that they were on him again about what a liability the pharmacy was. I asked him how we could be a liability considering we ran in the black and the hospital needed us to function. He said that it was because labs and pharmacies don’t generate revenue, they just consume it. Which I took to mean that the hundreds of dollars patients paid per day didn’t apply to anything pharmacy or lab related. We had an outpatient pharmacy up and running soon after that; I am not sure what the lab did to justify their existence. Sometimes I wonder if they ever figured out a way to have Environmental Services generate revenue too.

Dr. Dawson’s blog makes a nuclear point I didn’t know how to say, but he did, “Not accepting insurance is the ultimate affirmation that business does not define medicine or psychiatry.”

If we are not seeing patients and not doing therapy, I fail to see the point of psychiatric residency. Just hang out in Costa Rica for a year studying Stahl’s Essential Psychopharm (but not Schatzberg, because…well that’s for another post). It’s cheaper and more fun than the hard work of residency. Eighty percent of the purpose of residency is to gain experience seeing and treating patients, and if we’re not going to do that, why waste three years? If you’re in a psychiatric residency right now and you are on board with the collaborative care model, you are wasting your time. Because you are not going to be seeing patients after you finish.

Since Summergrad is a residency director, I’d really like to ask him why he is overtraining people for the job he is asking them to do. I can see the point of fraternity hazing more than psych residency if patient care isn’t the goal.

To quote Dr. Dawson’s excellent post, linked above: “… psychiatrists need to be trained in neurology, neuroscience, medicine, and psychotherapy. Not accepting insurance is the ultimate affirmation that business does not define medicine or psychiatry.”

Psychiatry is ideally a field for generalists, something like primary care physicians (PCPs) of the mind. Wielding a variety of conceptual angles (neuroscience, psychodynamics, cognition) and associated tools ensures that we don’t see everything as a nail because all we have is a hammer. PCPs handle most, but not all, of what comes their way, and are positioned to have the best view of a patient’s overall medical status. Likewise, as a generalist psychiatrist I handle most psychopharm, many cognitive interventions, and all dynamic psychotherapy for the patients I see — but I’m not averse to referring the occasional patient to a colleague whose emphasis skews more toward what that particular patient needs. Some of us focus more on meds, some on therapy (sadly, fewer of late), but all of us need to know neurology, medicine, and psychotherapy. And, I would add, at least a little social psychology and humanities as well.

Insurance and related business interests don’t find traditional primary care cost effective. PCPs are raising hell on sites like KevinMD; they’re choking on paperwork and low reimbursement, they’re highly demoralized and bitter. Fewer med students are choosing primary care, and very few PCPs recommend it as a career choice to their own children. “Direct pay” (non-insurance) practice is increasingly touted as the only viable model going forward.

It appears many of us psychiatrists simply got the memo a little earlier. Psychiatry, like primary care medicine, is fast becoming two-tier: practiced at the level of professional excellence when business does not define it, and something tragically less when it does.

In one part of my blog that was not included above, I point out that some people think “… psychiatrists are the physicians who talk to people and understand their concerns. I will …just point out that these attributes should be intrinsic to all of medical practice. It does medicine as a profession a disservice to have a single discipline that is considered the holder of a humanistic approach to human suffering.”
I think every primary care doc should have more time. In that way, I am in full agreement with many of the comments above.
Daniel Kahnemann and his colleagues in cognitive psychology/behavioral economics teach us that we are all influenced by economics. I do not see how we escape this. I am by no means defending the current practices of the insurance companies and I wish that every doctor on the front lines would be rewarded for listening and talking to patients, family members, and other colleagues. I appreciate and respect the kind of practice Dr. Dawson describes in his blog and I share his frustration that this high level of care was not financially sustainable. Maybe I am still not being clear because that remains intrinsic to the work I do and I am not suggesting that it gets dropped. I am not questioning that my colleagues commenting here practice in a humane and caring way and bring everything that they have learned into their work in a good and helpful way.
But as Dr. Nardo points out above, to some extent we brought this on ourselves:
“there had been a lot of billing medical insurance for long therapies or hospitalizations, many of which were optional – treatment recommendations based on what the insurance coverage would bear.” That was before managed care.
Funny thing, my years of working in the manner I described above did not seem to lead me to becoming a pez dispenser; if anything I am accused by some of being too critical of drug treatments.

Dr. Steingard,

“…we are all influenced by economics.”

I agree. Resources are finite. Yet, doesn’t the fact that there were abuses of insurance reimbursements in the beginning, and that there was a draconian reaction swinging too far the other way demonstrate that they are not the best parties to be managing how resources are allocated? They get it wrong both ways.

The most responsible way is for patients to pay for their own care. For the indigent, I understand someone has to manage the funds and the payments. I wish everyone were behaving ethically, however, if there are abuses to be dealt with. I would rather the need be to curb over billing/too much care vs being charged more each year (premiums/taxes) for less care. Although, I still think both happen today even after slashing reimbursements.

I’m just having a tough time getting around the fact that a large amount of money is being extracted from medical care by third parties to no clinical or societal benefit or that government is in effect doing the same thing when they claim they need taxes for mental health care then proceed to spend it on whatever they wish.

“there had been a lot of billing medical insurance for long therapies or hospitalizations, many of which were optional – treatment recommendations based on what the insurance coverage would bear.”

This certainly was true but had been pretty much shut down by the end of the eighties. I remember moonlighting as a resident and seeing people hospitalized for many months, Chestnut Lodge style, for adjustment and personality disorders. I knew at that time that the hammer would come down and I would be paying the price for the age of health insurance as an ATM card circa 1965-1985. But even during those horn o plenty days, the seriously mentally ill were being neglected. These same hospitals catering to the worried well would not accept Medicare.

Even back then I argued that mental health insurance should cover only serious mental illness and cover it well but forget the rest, because the increase in premiums would not be sustainable. But the APA was like the National Board of Realtors, in permanent PR mode always asking for more and more and not paying attention to the numbers.

During the last two years of my residency, I went to psychodynamic psychotherapy twice a week and I think my monthly deductible was something like 200 dollars. While this was an enormous benefit to me personally, you didn’t have to be a math major to figure out what would happen if everyone did this.

It remains my position that psychotherapy for problems of everyday living should be considered equivalent to routine maintenance of a home. Something everyone should do but that should not be charged to homeowner’s insurance.

APA and the profession in general made a huge mistake in trying to be everything to everyone paid for without questions by third parties. In 1985 we had adolescents in the hospital for six month on the basis of a conduct disorder, but today we can’t hospitalize a suicidal or homicidal schizophrenic for me than three days without constant harassment (from the courts as well as insurance).

There’s got to be a middle ground. And if all of these ACA cronies and shareholders are raking in obscene profits for the skill of being well connected, then I would submit that those margins need to be cut to the bone first.

Oh wait, here’s some money I found circling the drain in the government procurement commode:

http://www.politico.com/story/2014/05/obamacare-cost-failed-exchanges-106535.html

You want to be cost effective, ACA managers? How about some lemon laws and high profile lawsuits against these ripoff IT crony capitalist companies that are effectively siphoning money from the system that could be used for the chronically mentally ill?

Mangled collaborative care won’t save but a small fraction of this kind of waste.

On the financial viability issue:

In my experience financial viability is just more managed care rhetoric. Like cost effectiveness it needs to be rejected outright. The most obvious evidence is the collaborative care model. Here we have a model that is strongly promoted by managed care and now the APA that is telling us that there are essentially unlimited resources to see what are called “med management” visits. They are after all eliminating any actual diagnostic process and putting people on medications as soon as possible. I am quite sure that some of the patients with complex problems that I assessed are now getting a PHQ-9 and placed on antidepressants. I have already posted that (based on 2005-2010) data that antidepressants are already being overprescribed. Collaborative care will result in a proliferation of additional “prescribers” to increase that number. For that questionable low quality service, the patient will probably be charged around $50 for (at the maximum) a 10 or 15 minute visit. In fact, in my health plan it can occur over the telephone with no actual patient visit. If I was in private practice I would probably charge $300-350 for a 60-90 minute evaluation that look at all of the patients medical, psychiatric, and medical imaging data. The final product is a diagnosis or list of diagnoses rather than a PHQ-9 score and there would be an intelligent discussion with the patient about what to do. If medications were prescribed there would be a detailed discussion of the risk, benefit, and likelihood of success. There would also be a detailed discussion of how to avoid rare but serious side effects and when the medication should be stopped and when I should be called if there were problems.

If you want to say that “financial viability” is a legitimate metric that exists outside of the mind of an managed care MBA, I would clearly disagree. My plumber, electrician, and chimney sweep don’t hesitate to charge me $200 to show up and then add charges on top of that. The information content and technical skill they use to fix or install things does generally not reach the level that I would use in my 60-90 assessment. Financial liability in a managed care system is basically anything outside of high volume low quality work that the company can profit from. It is an artifact of cartel pricing that seriously discounts the skills of physicians. The only reason my tradesmen are financially viable is that they don’t have a cartel fixing their prices, forcing them to put out a high volume, low quality product and skimming their profits.

I hope that more and more physicians stop taking managed care insurance and put the financial viability theory to a test. It certainly has not put tradespeople out of business and they are easily charging on par what physicians charge for reasonable medical care. We can also learn a lot from our dental colleagues who are usually subject to severe insurance limitations. I guess that dentists are also not financially viable?

I respect Dr. Mickey’s mourning for his profession, and the pain expressed by the other clinicians here who have attempted to do right by patients.

However, oppression and limitations by managed care are only the outcome of a fate psychiatry designed for itself. The gummint as well as everybody else who’s been exposed to the propaganda for the last 20 years believes it’s the drugs that do the work and anybody can prescribe them safely and effectively.

As thelastpsychiatrist wrote in 2006 Massacre of the Unicorns http://thelastpsychiatrist.com/2006/11/massacre_of_the_unicorns.html

Myths of psychiatry …. are not isolated examples of poor practice or lack of knowledge, but are the unavoidable manifestations of an artificial paradigm which is arbitrarily derived from unproven assumptions, justified by inappropriate logic. They often lead to ineffective, dangerous, and very expensive treatment. Psychiatry must be more vigilant about its own data. It is necessary to avoid laziness in our education and understand from where comes our knowledge. There are daily diatribes against the influence of pharmaceutical companies; but the effect of pens and detailing is surely much smaller than the effect of misunderstood data, poorly researched axioms, and signs run amok. Psychiatry will not survive as a medical subspecialty if it continues along this path. It will lose its dignity, and worse, it will become irrelevant.

That’s a great essay. Thanks for posting Altostrata.

Not only is residency irrelevant under the new model but all fellowships except forensic (because that allows you to get paid outside ACA.) Unless the resident or fellow completely rejects the APA model and commits to the 1970s model of what a psychiatrist does.

“However, oppression and limitations by managed care are only the outcome of a fate psychiatry designed for itself.”

Psychiatry may well have created its own fate; one that is still being unveiled. However, if you are familiar with the nature of business, the field of psychiatry has little to do with oppression or limitations by managed care. That is what they do.

For the unproven assumptions and inappropriate logic in this area, I’m thinking that can last a long time, with or without psychiatrists. It reminds me of this quote about the stock market.

“The market can stay irrational longer than you can stay solvent.” – John Maynard Keynes

I am familiar with the nature of business, thank you, Arby. Also the nature of regulation, the nature of lobbying, the nature of medical specialties, and the trend of incursion on specialist turf by allied health professionals.

Altostrata, that wasn’t meant as an insult.

For the environment I was in, psychiatry could have been as pure as the driven snow and it would not have made any difference in how it was “managed”. So, I am curious to know how do you see them different from other specialties that I would also say are being overrun by managed care?

The lack of an evidence base, Arby.

The lack of an evidence base — or the use of a thoroughly fraudulent one — is not unique to psychiatry. (If only it were so!) They are just a little further along. And the role of the insurance companies in stripping out human beings from the health care equation, replacing them with pills, is not confined to psychiatry either.

In a wonderful article in yesterday’s NY Times, Barry Meier called out the insurance industry for its part in fueling the prescription opioid crisis.

http://www.nytimes.com/2014/05/11/business/a-soldiers-war-on-pain.html

Real pain mgt that lets people get on with their lives, can be done without OxyContin — and done far, far better. But it takes people. It takes time. And it’s infinitely harder to get that type of treatment than it was 30 years ago — in large part because for-profit managed care decided that Oxy was cheaper. For-profit Pharma was delighted. And for-profit medicine closed its eyes and followed the money.

I think something very similar happened in the late 70’s, early 80’s when Managed Care started saying it would only pay for Serious Mental Illness — and that to be on that roster, you had to prove your biological street cred. What they got, of course, was an unbeatable economic incentive to declare every form of human distress a Biological Brain Disease.