Well, it happened again. I attended yet another professional conference this weekend (specifically, the annual meeting of my regional psychiatric society), and—along with all the talks, exhibits, and networking opportunities—came the call I’ve heard over and over again in venues like this one: We must get psychiatrists involved in organized medicine. We must stand up for what’s important to our profession and make our voices heard!!
Is this just a way for the organization to make money? One would be forgiven for drawing this conclusion. Annual dues are not trivial: membership in the society costs up to $290 per person, and also requires APA membership, which ranges from $205 to $565 per year. But setting the money aside, the society firmly believes that we must protect ourselves and our profession. Furthermore, the best way to do so is to recruit as many members as possible, and encourage members to stand up for our interests.
This raises one important question: what exactly are we standing up for? I think most psychiatrists would agree that we’d like to keep our jobs, and we’d like to get paid well, too. (Oh, and benefits would be nice.) But that’s about all the common ground that comes to mind. The fact that we work in so many different settings makes it impossible for us to speak as a single voice or even (gasp!) to unionize.
Consider the following: the conference featured a panel discussion by five early-career psychiatrists: an academic psychiatrist; a county mental health psychiatrist; a jail psychiatrist; an HMO psychiatrist; and a cash-only private-practice psychiatrist. What might all of those psychiatrists have in common? As it turns out, not much. The HMO psychiatrist has a 9-to-5 job, a stable income, and extraordinary benefits, but a restricted range of services, a very limited medication formulary and not much flexibility in what she can provide. The private-practice guy, on the other hand, can do (and charge) essentially whatever he wants (a lot, as it turns out); but he also has to pay his own overhead. The county psychiatrist wants his patients to have access to additional services (therapy, case management, housing, vocational training, etc) that might be irrelevant—or wasteful—in other settings. The academic psychiatrist is concerned about his ability to obtain research funding, to keep his inpatient unit afloat, and to satisfy his department chair. The jail psychiatrist wants access to substance abuse treatment and other vital services, and to help inmates make the transition back into their community safely.
Even within a given practice setting, different psychiatrists might disagree on what they want: Some might want to see more patients, while delegating services like psychotherapy and case management to other providers. On the other hand, some might want to spend more time with fewer patients and to be paid to provide these services themselves. Some might want a more generous medication formulary, while others might argue that the benefits of medication are too exaggerated and want patients to have access to other types of treatment. Finally, some might lobby for greater access to pharmaceutical companies and the benefits they provide (samples, coupons, lectures, meals, etc), while others might argue that pharmaceutical promotion has corrupted our field.
For most of the history of modern medicine, doctors have had a hard time “organizing” because there has been no entity worth organizing against. Today, we have some definite targets: the Affordable Care Act, big insurance companies, hospital employers, pharmacy benefits managers, state and local governments, malpractice attorneys, etc. But not all doctors see those threats equally. (Many, in fact, welcome the Affordable Care Act with open arms.) So even though there are, for instance, several unanswered questions as to how the ACA (aka “Obamacare”) might change the health-care-delivery landscape, the ramifications are, in the eyes of most doctors, too far-removed from the day-to-day aspects of patient care for any of us to worry about. Just like everything else in the above list, we shrug them off as nuisances—the costs of doing business—and try to devote attention to our patients instead of agitating for change.
In psychiatry, the conflicts are particularly wide-ranging, and the stakes more poorly defined than elsewhere in medicine, making the targets of our discontent less clear. One of the panelists put it best when she said: “there’s a lot of white noise in psychiatry.” In other words, we really can’t figure out where we’re headed—or even where we want to head. At one extreme, for instance, are those psychiatrists who argue (sometimes convincingly) that all psychiatry is a farce, that diagnoses are socially constructed entities with no external validity, and that “treatment” produces more harm than good. At the other extreme are the DSM promoters and their ilk, arguing for greater access to effective treatment, the medicalization of human behavior, and the early recognition and treatment of mental illness—sometimes even before it develops.
Until we psychiatrists determine what we want the future of psychiatric care to look like, it will be difficult for us to jump on any common bandwagon. In the meantime, the future of our field will be determined by those who do have a well-formed agenda and who can rally around a common goal. At present, that includes the APA, insurance companies, Big Pharma, and government. As for the rest of us, we’ll just pick up whatever scraps are left over, and “organize” after we’ve finished our charts, returned our calls, completed the prior authorizations, filed the disability paperwork, paid our bills, and said good-night to our kids.