Why do psychiatrists do what they do? How— and why— is a psychiatrist different from a psychotherapist? I believe that most psychiatrists entered this field wanting to understand the many ways to understand and to treat what’s “abnormal,” but have instead become caught up in (or brainwashed by?) the promises of modern-day psychopharmacology. By doing so, we’ve found ourselves pigeonholed into a role in which we prescribe drugs while others provide the more interesting (and more rewarding) psychosocial interventions.
Exceptions certainly do exist. But psychiatrists are rapidly narrowing their focus to medication management alone. If we continue to do so, we’d better be darn sure that what we’re doing actually works. If it doesn’t, we may be digging ourselves a hole from which it will be difficult—if not impossible—to emerge.
How did we get to this point? I’m a (relatively) young psychiatrist, so I’ll admit I don’t have the historical perspective of some of my mentors. But in my brief career, I’ve seen these influences: training programs that emphasize psychopharmacology over psychotherapy; insurance companies that reimburse for medication visits but not for therapy; patients who demand medications as a quick fix to their problems (and who either can’t access, or don’t want, other therapeutic options); and treatment settings in which an MD is needed to prescribe drugs while the “real work” is done by others.
But there’s yet another factor underlying psychiatry’s increasing separation from other behavioral health disciplines: Continuing Medical Education, or CME.
All health care professionals must engage in some sort of professional education or “lifelong learning” to maintain their licenses. Doctors must complete CME credits. PAs, nurses, psychologists, social workers, and others must also complete their own Continuing Education (CE) credits, and the topics that qualify for credit differ from one discipline to the next.
The pediatrician and blogger Claudia Gold, MD, recently wrote about a program on “Infant-Parent Mental Health,” a three-day workshop she attended, which explored “how early relationships shape the brain and influence healthy emotional development.” She wrote that the program “left me well qualified to do the work I do,” but she couldn’t receive CME credits because they only offered credit for psychologists—not for doctors.
I had a similar experience several years ago. During my psychiatry residency, I was invited to attend a “Summit for Clinical Excellence” in Monterey, sponsored by the Ben Franklin Institute. The BFI offers these symposia several times a year; they’re 3- or 4-day long programs consisting of lectures, discussions, and workshops on advanced mental health topics such as addictions, eating disorders, relationship issues, personality disorders, trauma, ethics, etc.—in other words, areas which fall squarely under the domain of “mental health,” but which psychiatrists often don’t treat (mainly because there are no simple “medication solutions” for many of these problems).
Even though my residency program did not give me any days off for the event (nor did they provide any financial support), I rearranged my schedule and attended anyway. It turned out to be one of the most memorable events of my training. I got to meet (yes, literally meet, not just sit in an audience and listen to) influential figures in mental health like Helen Fisher, Harville Hendrix, Daniel Amen, Peter Whybrow, and Bill O’Hanlon. And because most of my co-attendees were not physicians, the discussions were not about medications, but rather about how we can best work with our patients on a human and personal level. Indeed, the lessons I learned there (and the professional connections I made) have turned out to be extraordinarily valuable in my everyday work. (For a link to their upcoming summits, see this link. Incidentally, I am not affiliated with the BFI in any way.)
Unfortunately, like Dr Gold, I didn’t receive any CME credits for this event either, even though my colleagues in other fields did get credit. A few days ago, out of curiosity, I contacted BFI and inquired about their CME policy. I was told that “the topic [of CME] comes up every few years, and we’ve thought about it,” but they’ve decided against it for two reasons. First, there’s just not enough interest. (I guess psychiatrists are too busy learning about drugs to take time to learn about people or ideas.) Second, they said that the application process for CME accreditation is expensive and time-consuming (the application packet “is three inches thick”), and the content would require “expert review,” meaning that it would probably not meet criteria for “medical” CME because of its de-emphasis of medications.
To be fair, any doctor can attend a BFI Summit, just as anyone could have attended Dr Gold’s “Infant-Parent Mental Health” program. And even though physicians don’t receive CME credits for these programs, there are many other simple (and free, even though much of it is Pharma-supported) ways to obtain CME.
At any rate, it’s important—and not just symbolically—to look at where doctors get their training. I want to learn about non-pharmacological, “alternative” ways to treat my patients (and to treat patients who don’t fit into the simple DSM categories—which is, well, pretty much everyone). But to do so, it would have to be on my own dime, and without CME credit. On the other hand, those who do receive this training (and the credit) are, in my opinion, prepared to provide much better patient care than those of us who think primarily about drugs.
At the risk of launching a “turf war” with my colleagues in other behavioral health disciplines, I make the following proposal: if psychologists lobby for the privilege to prescribe medications (a position which—for the record—I support), then I also believe that psychiatrists should lobby their own professional bodies (and the Accreditation Council for CME [ACCME]) to broaden the scope of what counts as “psychiatric CME.” Medications are not always the answer. Similarly, neurobiology and genetics will not necessarily lead us to better therapeutics. And even if they do, we still have to deal with patients—i.e., human beings—and that’s a skill we’re neither taught nor encouraged to use. I think it’s time for that to change.