This question now comes up every day for me. Psychiatry needs to join the 21st century, someone tells me. Someone else sarcastically makes a comment about the fee-for-service model. Shortages are a big problem, according to the news. “Where are all the psychiatrists?” asks a recent article. The mayor of one city is being lauded for hiring volunteers to screen potential patients.
I write this for any reader but especially for my colleagues of all specialties in hopes of contributing to further thought on these issues. Psychiatry is in deep disarray. This is nothing new but what concerns me is what I perceive to be a paucity of constructive dialogue on these topics. If you are a psychiatrist you might know much of this. If you aren’t maybe it will clarify.
This is how I see things. You might not agree. I am nevertheless sure many are very concerned. We all need to start coming up with solutions.
Psychiatrists often practice in a kind of netherworld where few understand what we do. Our services, while in short supply, have been co-opted and repackaged in so many ways as to bewilder patients and colleagues and leave us with so few viable ways to use our skills for the highest good of patients. It seems we are very fragmented as a specialty.
There are plenty of “jobs” in psychiatry in clinics, hospitals and programs. Some of my colleagues have never worked at these sorts of places, having gone directly into private practice. Many of these jobs are where the soul of psychiatry is dying. I don’t know what the solution is but this setup is very ill-equipped for quality care for patients. It is rare to find a clinic where the MD perspective carries any weight. If it exists, I never got to see it.
There are clinics full of patients who see a psychiatrist possibly once or twice a year for fifteen minutes. These patients are often on waiting lists for that kind of care. Tragically, these may be the sickest patients psychiatrists see. It is near impossible to provide good care with that model with any psychiatric patient. The relationship cannot be sustained. A fragile patient above all has to trust his doctor or the follow-through suffers.
I recognize that this idea of relationship in medicine is now under attack. Many in health IT think the practice of medicine does not depend on that relationship. People think we could be replaced by apps or robots someday. I have to disagree. The tone of this kind of discourse is distressing to some of us. I can see why the conversation is evolving to exclude us and that concerns me. Technology should complement the work of doctors not obstruct it. We need to work to bridge these communication gaps.
I have worked at the programs, clinics and places where the chaotic onslaught of very difficult patient care, phone calls, faxes, emails and prescription requests was suffocating. The function of the MD was to provide refills of complex regimens for which there was often no clear documentation or justification and write or sign others’ mindless notes without questioning. It was demoralizing. I felt a loss of sense of accomplishment.
I don’t know how exactly anyone tolerates this work. If you do, I respect you greatly for trying to help these patients. Now these jobs I know include inpatient coverage during the day, as if there weren’t enough to do. The work in inpatient is so far from what most of us trained to do that we would do most anything to keep a patient out of a psychiatric hospital. The psychiatrists have no autonomy, no time and no backup unless there are residents. The hospitals used to be our safety net and they no longer function since they cannot keep patients and can do very little other than add medications too fast to assess any effect. I don’t know how this is fixable. Parity was supposed to help our patients and I don’t see it.
Leaving the world of caring for indigent patients with severe psychiatric problems was something I had to do. The degree to which my autonomy was compromised was so extreme that it felt unsafe. I know others have had this experience and I’m not alone.
Another faction of psychiatrists are lucky enough to live in areas where we are able to practice independently treating patients that can pay out of pocket. This allows us to practice psychiatry as we see fit and as we were trained. It allows us to choose patients that we can best help with our skills and try to help others get referrals. It is where a little of the magic still is, where we can see people get better, develop, mature, sometimes slowly and incrementally. In that vision is a deep and intimate view of another person that no one else may ever see. It is a privilege. Many who practice like this are insulated from the realities of what goes on in the rest of medicine.
How long this can continue is uncertain. Many things threaten this old-fashioned model since it is fee-for-service, which many think doctors should not be allowed to do. It gets harder every year with the administrative, bureaucratic and IT overhead in practice. If this situation becomes much harder psychiatry surely will be irreversibly decimated. There are many of us who will never go back to institutional work. We are also mostly unequipped to hire staff to fight with insurance companies. We have few options.
The leadership in psychiatry are researchers and other academic doctors. The work and atmosphere can be difficult but they tend to have time to go to teach and go to meetings. They are mostly grandfathered into board certification. Some see few patients. They can tend to lack an appreciation of how far things have deteriorated. My sense is that many are disappointed in them. I have great respect for those who trained me but I am much more concerned than they seem to be about the future of our specialty.
So when the Kenneth Cole billboard became a news item about fighting stigma, I thought it was positive that there was a response but I was very concerned that people that think this is a top issue for us. Stigma is a huge problem, but, worse, if people were actually to seek the treatment they need the system would implode since the doctors are not going to be there. There are too many urgent issues to name but here’s a start. We are really in a difficult position. We cannot afford to be divided and disempowered.
What about the aging workforce and shortage of psychiatrists? What about the working conditions in the clinics? What about the opiate epidemic? Who will be doing all those maintenances/detoxes and where? What about the terrible hospital coverage with all but the most expensive, health insurance? What about hospital closings? What about physician burnout and suicide? What about the problems with physician health programs abusing doctors? What about EHR? Privacy? Insurance companies refusing to pay for patients meds? What of the science that’s been corrupted? What about reproducibility? What about cleaning up the overprescribing for the disabled and elderly? Who is going to do it? It’s not that easy. What of the dismal statistics about child and adolescent mental health? What about the expectation of video/telemedicine and the same standard of care for the live visit? How can we deliver that? What about the standard of care? What is it? What kind of quality metrics could possibly serve us? We are all doing such very different things. Lastly, what of the burdensome maintenance of certification? The busywork is adding up very fast and wasting lots of precious time given the “shortage.”
Hospitals and clinics everywhere have been designed for mythical psychiatrists that function as mindlessly automatic efficient data clerks and prescription writers. People used to shop around for doctors. Now they shop for prescriptions, which are extremely unlikely to accomplish much in a vacuum. Psychiatry just does not work like that. The world needs to fully understand that a psychiatrist is neither an extravagance nor a drone. A psychiatrist is not an app either. A psychiatrist is a leader, supervisor, teacher, coordinator, connector and healer. Psychiatrists appropriately employed could help out in ways we have not been permitted to do.
Clinics are instead cutting further, starting to hire psychiatrists for collaborative care, where we would make recommendations on a patient we have never evaluated. There may be some roles for these supportive interventions but in the absence of a functional infrastructure in psychiatry we are getting further and further from helping the patients.
I am hoping for colleagues to speak up more publicly. Perhaps its too late. Maybe people think we should just go gracefully into the night. Maybe I’m looking in the wrong places.
We need to educate our medical colleagues, the public and the patients about what a real psychiatrist does. A psychiatrist is trained to evaluate patients in a biopsychosocial model and treat accordingly. This involves many sophisticated, disparate and overlapping skill sets that we build over years of experience. There are no easy shortcuts or quick fixes. The attempts to provide shortcuts almost always backfire. The human element in psychiatry defies predictability a lot. Humility, curiosity, compassion and patience are always required.
It is a not a “backup” job for other differently trained professionals. It is its own complete set of skills that stands alone. Many of us have double or triple certificates or other kinds of advanced training. People tend to need us where others have tried and expert eyes are now needed. It involves much science, nuance, complexity, contradiction and controversy. That does not make it irrelevant. As far as I can see, there are some enormous problems for which we are very much needed.
The silence and mystery around us is no longer serving us, if it ever did. Patients will hopefully understand that we need to be ourselves, stop hiding, and speak up partly to dispel some of the myths. I cannot be neutral about the endangerment of patients and the decay of our profession.
We have long been co-opted by anyone who can find a way. Stigma affects psychiatrists in a parallel way that it affects our patients. We have been bullied and beaten down. People sometimes don’t show much respect. It can be very difficult to handle the commentary that is devaluing, suspicious or attacking. Its easier to be silent or focus on tangential issues or politically “neutral” topics to avoid arguments.
But if we don’t stand for the profession itself, massive problems like suicide or opiate addiction or children’s mental health will fall not to us, but to people who aren’t appropriately trained or have simplistic or biased understanding of these complicated issues.
If you are practicing psychiatry, please let’s educate about how we practice. If you are a colleague, family member or a patient I hope you can support us. Please write, blog, write Op Eds and share on social media what we can do to help people. Lets face the critics, skeptics, anti-psychiatry movement and the drone of devaluing from everywhere, especially in the press. The patients need us to step up now and handle our own stigma and demoralization as a profession, so that when they do show up for help we are there. There have to be some solutions other than silence, which could lead to extinction.