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Talk Is Cheap

I work part-time in a hospital psychiatry unit, overseeing residents and medical students on their inpatient psychiatry rotations.  They are responsible for three to six patients at any given time, directing and coordinating the patients’ care while they are admitted to our hospital.

To an outsider, this may seem like a generous ratio: one resident taking care of only 3-6 patients.  One would think that this should allow for over an hour of direct patient contact per day, resulting in truly “personalized” medicine.  But instead, the absolute opposite is true: sometimes doctors only see patients for minutes at a time, and develop only a limited understanding of patients for whom they are responsible.  I noticed this in my own residency training, when halfway through my first year I realized the unfortunate fact that even though I was “taking care” of patients and getting my work done satisfactorily, I couldn’t tell you whether my patients felt they were getting better, whether they appreciated my efforts, or whether they had entirely different needs that I had been ignoring.

In truth, much of the workload in a residency program (in any medical specialty) is related to non-patient-care concerns:  lectures, reading, research projects, faculty supervision, etc.  But even outside of the training environment, doctors spend less and less time with patients, creating a disturbing precedent for the future of medicine.  In psychiatry in particular, the shrinking “therapy hour” has received much attention, most recently in a New York Times front-page article (which I blogged about it here and here).  The responses to the article echoed a common (and growing) lament among most psychiatrists:  therapy has been replaced with symptom checklists, rapid-fire questioning, and knee-jerk prescribing.

In my case, I don’t mean be simply one more voice among the chorus of psychiatrists yearning for the “glory days” of psychiatry, where prolonged psychotherapy and hour-long visits were the norm.  I didn’t practice in those days, anyway.  Nevertheless, I do believe that we lose something important by distancing ourselves from our patients.

Consider the inpatient unit again.  My students and residents sometimes spend hours looking up background information, old charts, and lab results, calling family members and other providers, and discussing differential diagnosis and possible treatment plans, before ever seeing their patient.  While their efforts are laudable, the fact remains that a face-to-face interaction with a patient can be remarkably informative, sometimes even immediately diagnostic to the skilled eye.  In an era where we’re trying to reduce our reliance on expensive technology and wasteful tests, patient contact should be prioritized over the hours upon hours that trainees spend hunched over computer workstations.

In the outpatient setting, direct patient-care time has been largely replaced by “busy work” (writing notes; debugging EMRs; calling pharmacies to inquire about prescriptions; completing prior-authorization forms; and performing any number of “quality-control,” credentialing, or other mandatory “compliance” exercises required by our institutions).  Some of this is important, but at the same time, an extra ten or fifteen minutes with a patient may go a long way to determining that patient’s treatment goals (which may disagree with the doctor’s), improving their motivation for change, or addressing unresolved underlying issues– matters that may truly make a difference and cut long-term costs.

The future direction of psychiatry doesn’t look promising, as this vanishing emphasis on the patient’s words and deeds is likely to make treatment even less cost-effective.  For example, there is a growing effort to develop biomarkers for diagnosis of mental illness and to predict medication response.  In my opinion, the science is just not there yet (partly because the DSM is still a poor guide by which to make valid diagnoses… what are depression and schizophrenia anyway?).  And even if the biomarker strategy were a reliable one, there’s still nothing that could be learned in a $745+ blood test that couldn’t be uncovered in a good, thorough clinical examination by a talented diagnostician, not to mention the fact that the examination would also uncover a large amount of other information– and establish valuable rapport– which would likely improve the quality of care.

The blog “1boringoldman” recently featured a post called “Ask them about their lives…” in which a particularly illustrative case was discussed.  I’ll refer you there for the details, but I’ll repost the author’s summary comments here:

I fantasize an article in the American Journal of Psychiatry entitled “Ask them about their lives!” Psychiatrists give drugs. Therapists apply therapies. Who the hell interviews patients beyond logging in a symptom list? I’m being dead serious about that…

I share Mickey’s concern, as this is a vital question for the future of psychiatry.  Personally, I chose psychiatry over other branches of medicine because I enjoy talking to people, asking about their lives, and helping them develop goals and achieve their dreams.  I want to help them overcome the obstacles put in their way by catastrophic relationships, behavioral missteps, poor insight, harmful impulsivity, addiction, emotional dysregulation, and– yes– mental illness.

However, if I don’t have the opportunity to talk to my patients (still my most useful diagnostic and therapeutic tool), I must instead rely on other ways to explain their suffering:  a score on a symptom list, a lab value, or a diagnosis that’s been stuck on the patient’s chart over several years without anyone taking the time to ask whether it’s relevant.  Not only do our patients deserve more than that, they usually want more than that, too; the most common complaint I hear from a patient is that “Dr So-And-So didn’t listen to me, he just prescribed drugs.”

This is not the psychiatry of my forefathers.  This is neither Philippe Pinel’s “moral treatment,” Emil Kraepelin’s meticulous attention to symptoms and patterns thereof, nor Aaron Beck’s cognitive re-strategizing.  No, it’s the psychiatry of HMOs, Wall Street, and an over-medicalized society, and in this brave new world, the patient is nowhere to be found.

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13 Responses to Talk Is Cheap

  1. doctorz says:

    Your best column yet, and one that mandates publication in the editorial sections of major newspapers. Forward it to the NY Times for consideration. More people in this country need to know that “cutting edge” psychiatry is a farce, a very costly and ineffective one at that.

  2. John Sawkins says:

    To use an analogy from cookery, it’s no use putting the lid on the pan if you don’t first turn down the heat. All that seems to be looked at is the reactions of the patient, and this is also true of physical ailments (we’ll give you a pain-killer). There seems to be no attempt to look into what provoked the reaction. Putting a lid on it merely delays recovery, with the patient condemned to have his or her feelings blunted. The underlying causes are ignored or dismissed. Eventually the patient realises he/she has to resolve his/her issues alone.

  3. Rob Lindeman says:

    Steve, I assume the “patients” you refer to are your voluntary patients. You can’t help somebody who doesn’t want your help. I fear this applies to a fair number of the in-patients your residents “take care of”.

    And thank you for pointing out the obvious as to the relationship between residents and “their patients”. I too labored under the misconception that I was actually caring for children to whom I was assigned as a resident. It was nonsense. At best, the nurses assigned to them cared for them. I wrote orders.

  4. Andrea says:

    I have been receiving treatment for bipolar disorder for 22 years. When I have been hospitalized, I have usually only spoken with psychiatrists for 5 minutes at a time–not even every day. I have always fared better as an outpatient with psychiatrists who spent more time with me than they had to. I had one psychiatrist who also provided therapy, which was excellent, but I had to move and haven’t found any other psychiatrists who practice that way. I am thankful that I have a good therapist now and that my psychiatrist usually spends 30 to 45 minutes with me even though I am only paying for 15 minutes.

  5. Thank you for this article. I’m going to post and repost every where I can. People need to read this, get this insight.

  6. leejcaroll says:

    “$745+ blood test…”, if they spend time talking that costly test might not be able to be justified. Question asked, question answered.

  7. Talk may not be cheap, it’s just cheaper than the alternatives. Great post.

  8. bjcirceleb says:

    I have NEVER met a person who does not want help. Just because they do not want what you want, does not mean they do not want help. Disagreeing with you is not about lacking insight, and nor is it about not wanting help. You are not in our bodies, you do not know what side effects are tolerable for us, and which are not. You are not the one living with this condition. Only WE can know if the beneifts outweigh the side effects. Since you are not in our bodies you cannot possibly know that. It never ceases to amaze me that the ONLY area of medicine in which it is impossible to truly treat a person without talking to them, is the area in which they pay less attention and less respect to us as human beings.

  9. Mariam Cohen, MD says:

    I did two years of residency in OB/Gyn after medical school and I was roundly criticized then for spending too much time talking with my patients. When I transferred into psychiatry I enjoyed the time getting to know my patients.
    Now, it seems that the trend is to tell me again that I’m spending too much time talking with my patients.
    Sad.

  10. Daniela says:

    Well, I DID train and practice back in the day when the 50 minute psychotherapy hour was the standard of care, for psychiatrists. But then I trained in the mecca, New York City. Friends training in other parts of the country were not so fortunate, but they didn’t seem to feel the need, and scoffed at my old-fashioned preference for close listening to the patient, and using “tact, timing and dosage” when speaking. Close listening and careful speaking have never betrayed me. Can’t say the same for prescribing.

  11. SeanL says:

    There is a logical fallacy in your analysis. “This is not the psychiatry of my forefathers.” I’m not sure if that would be a good thing if we were stuck in an era where people were massively hospitalized in state institutions and what consists of “therapy” was mired in the psychoanalytic tradition. Whereas you decry the “brave new world”, I think measurement based care should be the standard of care. You think talk is cheap. In fact, the opposite problem is haunting us. Talk is actually extremely expensive and only the rich and privileged can afford psychoanalytically oriented therapy. The capacity for our healthcare system to handle a large number of severe, persistent mentally ill critically depend on a new generation of psychiatrists who are well versed in systems based care, exactly the type of knowledge that you are so eager to criticize as “wall street”.

    • stevebMD says:

      Sean,

      Thanks for your comments. I’m not advocating for a return to the psychoanalytic tradition, but simply to a time in our past when we really tried to understand our patients and listen for the deeper meaning of their symptoms and complaints, rather than constantly being on the lookout for key words/phrases that allow us to make a DSM diagnosis.

      I agree with you that measurement-based care is important (otherwise, how do we get people to pay for treatment, and for the medical field to take us seriously?), but we run the risk of treating the symptoms, not the person. A 5-point improvement in MADRS score or a reduction in panic attack frequency is admirable, but not if the person is still incapacitated or otherwise compromised. One might reasonably argue that those other aspects of a person’s presentation are better handled outside of the realm of “psychiatry,” but I happen to believe they comprise the core of what we ought to be doing, and are essential for the ultimate well-being of the patient.

      My comment that “talk is cheap” was meant to be ironic. I agree, psychoanalytically oriented therapy is not cost-effective. But there are several forms of one-on-one, or group, intervention that are far cheaper than the scan for symptoms and the knee-jerk prescription of a drug. In fact, your reference to the management of “severe, persistent mentally ill” patients is apt, since these are exactly the patients who might benefit more from ongoing psychosocial intervention, which would be cheaper than the thousands per year we spend on biomedical treatments.

      Finally, I referred to “Wall Street” as one of several influences that dictate how and what we do. And no, I don’t see it as equivalent to “knowledge of systems-based care,” it’s a desire for profit. Pure and simple. Not that “profit” is necessarily bad, of course, but trust me, Bristol-Myers Squibb and its shareholders (to take one example) are not interested in the well-being of your patients or of society as a whole. I’ll give you one guess as to what they are interested in.

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    Talk Is Cheap | Thought Broadcast

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