Last weekend’s NY Times article, which I wrote about in my last post, has, predictably, resulted in a deluge of responses from many observers. The comments posted to the NYT “Well” blog (over 160 as of this writing) seem to be equally critical of Dr Levin and of our health care reimbursement system, which, according to the article, forced him to make the Faustian bargain to sacrifice good patient care in favor of a comfortable retirement. Other bloggers and critics have used this as an opportunity to champion the talents and skills of psychologists, psychotherapists, and nurse practitioners, none of whom, according to the article, face the same financial pressures—or selfishness—of psychiatrists like Dr Levin.
While the above observations are largely valid (although one colleague pointed out that psychologists and NPs can have financial pressures too!), I chose to consider the patients’ point of view. In my post, I pointed out that many patients seem to be satisfied with the rapid, seemingly slapdash approach of modern psychopharmacology. I wrote how, in one of my clinic settings, a community mental health center, I see upwards of 20-30 patients a day, often for no more than 10-15 minutes every few months. Although there are clear exceptions, many patients appreciate the attention I give them, and say they like me. The same is also true for patients with “good insurance” or for those who pay out-of-pocket: a 15-minute visit seems to work just fine for a surprising number of folks.
I remarked to a friend yesterday that maybe there are two types of patients: those who want hour-long, intense therapy sessions on an ongoing basis (with or without medications), and those who are satisfied with quick, in-and-out visits and medication management alone. My argument was that our culture has encouraged this latter approach in an unfortunate self-propagating feedback cycle: Not only does our reimbursement process force doctors (and patients) to accept shorter sessions just to stay afloat, but our hyperactive, “manic” culture favors the quick visits, too; indeed, some patients just can’t keep seated in the therapist’s chair for more than ten minutes!
She responded, correctly, that I was being too simplistic. And she’s right. While there are certainly examples of the two populations I describe above, the vast majority of patients accept it because the only other option is no care at all. (It’s like the 95% of people with health insurance who said during the health care reform debate that they were “satisfied” with their coverage; they said so because they feared the alternative.) She pointed out that the majority of patients don’t know what good care looks like. They don’t know what special skills a psychiatrist can bring to the table that a psychologist or other counselor cannot (and vice versa, for that matter). They don’t know that 15 minutes is barely enough time to discuss the weather, much less reach a confident psychiatric diagnosis. They don’t know that spending a little more money out of pocket for specialized therapy, coaching, acupuncture, Eastern meditation practice, a gym membership, or simply more face-time with a good doc, could result in treatment that is more inspiring and life-affirming than any antidepressant will ever be.
So while my colleagues all over the blogosphere whine about the loss of income wrought by the nasty HMOs and for-profit insurance companies (editorial comment: they are nasty) and the devolution of our once-noble profession into an army of pill pushers, I see this as a challenge to psychiatry. We must make ourselves more relevant, and to do so we have to let patients know that what we can offer is much more than what they’re getting. Patients should not settle for 10 minutes with a psychiatrist and a hastily written script. But they’ll only believe this if we can convince them otherwise.
It’s time for psychiatrists to think beyond medications, beyond the DSM, and beyond the office visit. Psychiatrists need to make patients active participants in their care, and challenge them to become better people, not just receptacles for pills. Psychiatrists also need to be doctors, and help patients to understand the physical basis of mental symptoms, how mental illness can disrupt physical homeostasis, and what our drugs do to our bodies.
Patients need to look at psychiatrists as true shepherds of the mind, soul, and body, and, in turn, the psychiatrist’s responsibility is to give them reason to do so. It may cost a little more in terms of money and time, but in the long run it could be money well spent, for patients and for society.
Psychiatrists are highly educated professionals who entered this field not primarily to make money, but to help others. If we can do this more effectively than we do now, the money will surely follow, and all will be better served.
Thought Broadcast 
“inspiring and life-affirming… better people… true shepherds of the mind, soul, and body”
What are you, a physician or a guru? One reason for the negative reception of the Levin article is that we have perpetuated the myth implied by the quote above. I’m just a doctor, and my patients are fine just the way they are. They don’t need me to make them “better people” thank you very much.
And nobody “forced” us to do anything.
This is a really thought-provoking post. I’m a med student and very interested in both the microeconomics of healthcare and psychiatry, so this hits home to me. Changing attitudes to change demand is a great example of using the power of “the business of medicine” for good.
Awesome job.
moviedoc, if by “guru” you mean someone who endeavors to treat not just the physical but also the cognitive, psychological, and (dare I say) spiritual components of illness, then yes, I suppose I’m guilty as charged.
If you’re “just a doctor” by seeing a patient for 15-20 minutes and writing a script, then my prediction is that you won’t be for long. There are NPs, PAs, psychologists, and plenty of other MDs who will be glad to take over your role, and plenty of third-party payers who will gladly pay them (less) for it.
The point of my post is that our system has “lowered the bar” for patients and for physicians. Your patients (and mine, too) are capable of more than feeling “fine just the way they are.” That’s what motivates me to come to work every morning, and that’s what psychiatrists (more so than other providers) can bring to the table.
AP, thanks for the comment. Many responses on the NY Times blog express outrage towards Dr Levin and psychiatry in general. The article may have glossed over some points, but public perception is what it is. If psychiatrists aren’t giving the public what it wants, we have to listen to them and change to meet their demand. And if we’re good at it, the money will follow.
How do you know most, or even many, patients are satisfied with the way things are? Do you actually think they’re going to sit there and tell you how to practice – tell you that they think the job you do is half-assed and that psychiatrists really ARE nothing but greedy pill-pushers? Do you actually think a patient is going to say that to your face? Even if you ask them point-blank what their thoughts are, I can guarantee you they won’t say this because they’re not going to do something that will offend the Big, Important Doctor. In the absence of this, how do you have any grounds to make statements about what patients think about you, your profession and the way you practice? You don’t. In doing so, as so many of your colleagues seem to be doing right now, you are justifying and deluding yourselves.
I know for a FACT that patients who feel like your profession is practiced in a negligent fashion and who, unfortunately, are at the receiving end of such half-assed treatment, feel you people are overpaid, greedy, prescription-writers who charge $100 for scribbling on a prescription pad and operate on a treadmill – but they would never ever tell you that. Your assumptions are self-important – yet another thing patients do not like about your profession.
Jill: If what you say is true, why do all those dissatisfied patients keep coming back for more negligent treatment? I suspect it’s because all they really want is the pills, and they are more than willing to exploit those greedy pill-pushers to get them.
Jill, I think your comments prove my point. I’m as surprised as you are that patients say they appreciate the time I give them—even if it’s far shorter than I would prefer if I were the patient. And yet, many people do seem to be satisfied with this level of care. Maybe patients have been “sold” on the promises of psychopharmacology. Maybe they have no idea what “better” treatment looks like. I don’t know, but as moviedoc points out, they do keep coming back, so something must be working.
(Incidentally, I work in two very different settings. In one, the rapid, medication-only visit is not only the norm, but deeper engagement with the patient is actively discouraged. The other is a private practice setting where I can work much more collaboratively with the patient. I’ll write more about this disparity in future posts.)
Regarding the patients who feel that psychiatrists are negligent or greedy, I encourage them to speak up. In fact, I want to know when my patients feel that I’m not helping them, or if they feel I might have other motives. Because if the patient’s wishes don’t align with the doctor’s, failure is a foregone conclusion. I’m not a “Big, Important Doctor.” Far from it, in fact. I bristle when I see my colleagues that display that attitude, but I also wish patients wouldn’t see us that way.
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