Do What You’re Taught

In my mail yesterday was an invitation to an upcoming 6-hour seminar on the topic of “Trauma, Addiction, and Grief.”  The course description included topics such as “models of addiction and trauma/information processing” and using these models to plan treatment; recognizing “masked grief reactions” and manifestations of trauma in clients; and applying several psychotherapeutic techniques to help a patient through addiction and trauma recovery.

Sound relevant?  To any psychiatrist dealing with issues of addiction, trauma, grief, anxiety, and mood—which is pretty much all of us—and interested in integrative treatments for the above, this would seem to be an entirely valid topic to learn.  And, I was pleased to learn that the program offers “continuing education” credit, too.

But upon reading the fine print, credit is not available for psychiatrists.  Instead, you can get credit if you’re one the following mental health workers:  counselor, social worker, MFT, psychologist, addiction counselor, alcoholism & drug abuse counselor, chaplain/clergy, nurse, nurse practitioner, nurse specialist, or someone seeking “certification in thanatology” (whatever that is).  But not a psychiatrist.  In other words, psychiatrists need not apply.

Well, okay, that’s not entirely correct, psychiatrists can certainly attend, and–particularly if the program is a good one—my guess is that they would clearly benefit from it.  They just won’t get credit for it.

It’s not the first time I’ve encountered this.  Why do I think this is a big deal?  Well, in all of medicine, “continuing medical education” credit, or CME, is a rough guide to what’s important in one’s specialty.  In psychiatry, the vast majority of available CME credit is in psychopharmacology.  (As it turns out, in the same batch of mail, I received two “throwaway” journals which contained offers of free CME credits for reading articles about treating metabolic syndrome in patients on antipsychotics, and managing sexual side effects of antidepressants.)  Some of the most popular upcoming CME events are the Harvard Psychopharmacology Master Class and the annual Nevada Psychopharmacology Update.  And, of course, the NEI Global Congress in October is a can’t-miss event.  Far more psychiatrists will attend these conferences than a day-long seminar on “trauma, addiction, and grief.”  But which will have the most beneficial impact on patients?

To me, a more important question is, which will have the most beneficial impact on the future of the psychiatrist?   H. Steven Moffic, MD, recently wrote an editorial in Psychiatric Times in which he complained openly that the classical “territory” of the psychiatrist—diagnosis of mental disorder, psychotherapy, and psychopharmacology—have been increasingly ceded to others.  Well, this is a perfect example.  A seminar whose content is probably entirely applicable to most psychiatric patients, being marketed primarily to non-psychiatrists.

I’ve always maintained—on this blog and in my professional life—that psychiatrists should be just as (if not more) concerned about the psychological, cultural, and social aspects of their patients and their experience as in their proper psychopharmacological management.  It’s also just good common sense, especially when viewed from the patient’s perspective.  But if psychiatrists (and our leadership) don’t advocate for the importance of this type of experience, then of course others will do this work, instead of us.  We’re making ourselves irrelevant.

I’m currently experiencing this irony in my own personal life.  I’m studying for the American Board of Psychiatry and Neurology certification exam (the “psychiatry boards”), while looking for a new job at the same time.  On the one hand, while studying for the test I’m being forced to refresh my knowledge of human development, the history of psychiatry, the theory and practice of psychotherapy, the cognitive and psychological foundations of axis I disorders, theories of personality, and many other topics.  That’s the “core” subject matter of psychiatry, which is (appropriately) what I’ll be tested on.  Simultaneously, however, the majority of the jobs I’m finding require none of that.  I feel like I’m being hired instead for my prescription pad.

Psychiatry, as the study of human experience and the treatment of a vast range of human suffering, can still be a fascinating field, and one that can offer so much more to patients.  To be a psychiatrist in this classic sense of the word, it seems more and more like one has to blaze an independent trail: obtain one’s own specialized training, recruit patients outside of the conventional means, and—unless one wishes to live on a relatively miserly income—charge cash.  And because no one seriously promotes this version of psychiatry, this individual is rapidly becoming an endangered species.

Maybe I’ll get lucky and my profession’s leadership will advocate more for psychiatrists to be better trained in (and better paid for) psychotherapy, or, at the very least, encourage educators and continuing education providers to emphasize this aspect of our training as equally relevant.  But as long as rank-and-file psychiatrists sit back and accept that our primary responsibility is to diagnose and medicate, and rabidly defend that turf at the expense of all else, then perhaps we deserve the fate that we’re creating for ourselves.

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17 Responses to Do What You’re Taught

  1. Seems to me that psychiatrists are simply too expensive to do talk therapy. Why should patients have to pay for it? Unless you are going to charge the lower rates that social workers and many psychologists do, why should insurers pay for a qualification that isn’t needed?

    Alternatively, you could set yourselves up to get paid more if you branded yourselves as actually providing evidence-based talk therapy. Most of what you get from psychologists, social workers and even psychiatrists is not stuff that has been proven to work in clinical trials for particular conditions.

    If you actually provided that, you might be able to justify the extra dollars. The grief workshop might not qualify for CME’s in psychiatry because there’s no evidence behind it (Not sure about this and not disparaging the particular workshop since I know nothing of it, but I know that a lot of stuff like this is just people pronouncing a technique they like/developed useful, especially those who are good at self promotion).

    Otherwise, it makes most sense for MD’s to focus on psychopharmacology and ruling out physical causes of mental disorders [which is generally not done enough]. Obviously, one needs to realize the limits of drugs and refer out to talk therapy when it’s the best treatment or part of the best treatment.

    But why do you need an MD to do talk? And if you are arguing that you do need one, why should the other guys be allowed to do it?

    • stevebMD says:

      Maia, I think you hit the nail on the head when you write “…if you branded yourselves as actually providing evidence-based talk therapy.”

      I think there is indeed a role for the combined use of psychopharmacology and psychotherapy, and ideally by the same person (it’s more efficient, patients prefer it, and it’s more feasible in the modern fragmented health care system). And I believe that, with proper assessments, “referring out” to talk therapy is not necessarily what psychiatrists should do, because medication management may become necessary over time; this often can’t be determined in the first one or two visits. (Also, it’s easy for a psychiatrist to just “refer for therapy” cases whom he/she believes to be difficult, or who has a condition– like addictive or psychosomatic illness– for which there is no easy pharmacologic treatment.)

      To get the “evidence” you speak of, we need to stop doing sterile drug trials on patients who don’t resemble anything in the real world; we also need to stop promoting untested therapies or those promoted by hucksters and charlatans. But we do need to combine drug trials with more informed psychotherapeutic treatments, ideally using a more detailed understanding of patients and their unique clinical characteristics, like personality features, social background, and (if possible) biological features such as genotypes. Nothing like this exists right now. Psychiatrists should be spearheading this kind of research, but we’re not.

    • stevebMD says:

      Maia,

      Thinking about your comment further… Why should CME require an evidence base behind it?

      That’s sort of a rhetorical question. But in psychiatry at least, I think it’s far more important for a practitioner to be open-minded, well-rounded, accepting of alternate interpretations, and somewhat skeptical, than to be entirely data-driven (especially when the data are so questionable in this field).

      I often joked with med school classmates that the reason I chose psychiatry was because it was the one field of medicine in which reading a novel or watching a movie actually *helped* your practice. And as a patient, I could definitely say that it was more important for my providers to understand me as a human being (which is what popular culture helps with) than as a collection of symptoms or (even worse) as a DSM-IV diagnosis.

  2. David K says:

    FYI, “Thanatology” is, apparently, the “multi-disciplinary, scientific study of death,” except that it includes the humanities (which include the evidence, at times, but not the methods, of science) and theology (which is definitely not “science” in any manner of speaking). And, it seems to me to be rather pessimistic to the extreme (so to speak) to suggest that “certification in thanatology” might be a qualifier, since we’re dealing with brain/mind illnesses, don’t you think?

  3. Carol Levy says:

    I wonder if this about those who think that an MD is not relevant to anything other then having a prescription pad.
    (you might be interested in thi, post on lawyer’s blog about the issue of grief and DSM http://jonathanturley.org/2012/02/04/defining-grief/ )

  4. Liz says:

    thanks for posting this.

    in my experience, psychologists have treated me with greater respect and efficacy than psychiatrists, who have been (with one lovely old school exception) just pill pushers.

    i wish it wasn’t the case, but i think you are correct in your assertion that your profession is allowing itself to be made redundant. one of the best parts (in my mind) of no longer being on medication is that i no longer had to see a psychiatrist.

  5. Mara says:

    Regarding what Maia said about psychiatrists being too expensive to do talk…not necessarily. If they do talk therapy and med management, then that is more like a bargain. It’s not a bargain if you only want talk therapy, but it’s probably cheaper and less time consuming than hiring two different people for those who need meds and therapy. And actually…I would even imagine it would be safer for the patient. That way the pdoc can get a very clear image of how the patient is doing if there are weekly or biweekly appointments until the patient finds the right med. So many stories of people flipping out on these drugs or having terrible withdrawal! I would think this would be a better option. Especially for patients who have a hard time getting on and off meds or who are difficult to treat.

    It would be nice if insurance companies saw it that way and would allow more options in general. I could see why some people just want meds or just want therapy. Or even if they do want therapy and meds, maybe they juts don’t click with the pdoc in therapy (but do trust him with their meds). I think there is a place for pdocs who don’t do therapy and those who do. But it would be nice to have the option of meds and therapy by a pdoc for people who can only afford what insurance can offer.

  6. Dr. D says:

    It’s sad where the profession has ended up, and I’m never sure how much to blame the profession itself, versus the government or managed care/insurance companies. The unfortunate fact is that reimbursement for psychotherapy pales in comparison to brief medication management visits.

    I was recently in the Bay Area looking for child psychiatry jobs. One clinic I visited has a child psychiatrist who sees 20 patients per day (mostly 20-minute med visits), and he makes well over $300,000 per year. Another clinic actually has child psychiatrists who see patients and their families for hour-long therapy visits, focusing on family issues and using CBT for the depressed or anxious patients, while only prescribing medications when necessary. I suspect the families are happier with the care and outcomes are better. Unfortunately, the psychiatrists at clinic #2 make about half of what the ones at clinic #1 make.

    If only the incentives are aligned with doing the right thing.

    • stevebMD says:

      Dr. D,

      I just saw your comment and the following sentence: “One clinic I visited has a child psychiatrist who sees 20 patients per day (mostly 20-minute med visits), and he makes well over $300,000 per year.”

      Please do not insult my (and your) intelligence by calling this “psychiatry.” I hope to write a post about this sometime soon (although I’m trying to figure out how to do it while offending as few people as possible!!), but in my opinion it is absolutely impossible to see 20 or more patients a day (especially children) and do a competent, thorough job. You might call this “medication management” or “supportive med therapy,” and I’ll admit, there are some patients for whom this is acceptable, but far more often than not, a doctor who practices like this (a) regularly ignores other pertinent information that might be presented by the patient, (b) does not probe to determine alternate explanations for symptoms or presentations, and (c) jumps to a medication solution when a more helpful, less expensive, and less harmful (yet more time-consuming) option may exist.

      Regarding the child-psychiatry aspect: I work part-time with children. I spent 4.5 hours this morning with three patients (follow-ups!!). And it’s not because I’m slow, or because I do intensive therapy (or any therapy, for that matter– I have a “med management” job) with my patients. Instead, I make observations, ask questions, and collect data about what might really be causing the child’s dysfunction or impairment, which– for any child– demands a fairly exhaustive search. If I had simply followed what was in the chart and prescribed whatever med they got last month, I’d be doing nothing for the patient or the family.

      • Dr. D says:

        I agree wholeheartedly, Steve. Just as sophists were not philosophers, those practitioners who do 20 minute med checks should not be called psychiatrists. In the spirit of the times, I propose that we come up with a new name for people of this sort: $ychiatrists.

        As for your desire to write a post without offending too many people, I am very sympathetic to the dilemma. It’s hard to shame the shameless, but easy to piss them off. I think it’s wonderful that you’re sharing your thoughts without the use of a pseudonym, and I hope your posts continue to enlighten and provoke thought.

      • giannakali says:

        hi Steve…
        you may not want to call that psychiatry but the fact is it’s how most psychiatry is practiced today. I realize that you and a great many other doctors want to change that and that some of you practice otherwise, but it’s pretty much what goes on out there in the name of psychiatry. I’ve worked in several environments where the psychiatrists actually asked me for recommendations (including med changes etc) on clients and followed them because they didn’t have the time to sit with the patients and I did. Yes. No joke.

        And I’m sure you’ve not forgotten the New York Times article with the lovely (not) Dr. Levin: http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?_r=2&adxnnl=1&ref=health&adxnnlx=1299416796-fjHEo0icnaPLH7+LCds6gA

        he may lament that that is what has become of psychiatry but he fully and consciously makes decisions based only on his pocketbook to the detriment of his patients as do far too many of your colleagues.

  7. Carol Levy says:

    Like your new subspecialty Dr. D.

    As I read this about the meds I also wonder if for a lot of those dx’ed with ADD or ADHD if the meds allow them to “calm” down enough that they may be learning how to “not be” ADD, ADHD (sry I know there is a better way for me to write that) but because the meds seem to be working and are easier then checking and rechecking it is not worth taking them off the meds.

  8. Mariam Cohen, MD says:

    Most likely the grief etc., conference did not provide CME credits for psychiatrists because no one organizing it wanted to go through the incredible hoops that the Accreditation Council for Continuing Medical Education requires of organizations that want to provide medical CE credits.

    I work with an organization that does go through these hoops, and it requires a great deal of work to be able to provide CME credits.

    You lament the lack of CME credits for anything but psychopharmacology. The group I work with — the American Academy of Psychoanalysis and Dynamic Psychiatry — does provide CME credits for learning about doing psychotherapy. We’re an affiliate of the American Psychiatric Association and hold our meeting just before the APA convention, this year in Philadelphia. We also run a panel at the APA convention, and the APA convention program does include a fair number of panels, workshops, and courses on psychotherapy for psychiatrists.

    Needless to say, I am all for psychiatrists providing psychotherapy and getting all the training they need to do so. I teach psychodynamic psychotherapy to psychiatric residents and only lament that I don’t get all the time on their busy schedules to help them be really proficient at doing it.

  9. I don’t know if this is still common practice, but it used to be that most universities had depts or divisions of adult continuing education by profession/academic discipline.

    What about submitting requests for CME of topics of interest and/or offering yourself as continuing education faculty? In the latter case, those departments take on the wonderful processes of completing the CME application, submitting documents and fees, providing the meeting venue/web support, hosting, processing the attendees CME and providing the required means for course and presenter evaluations. You can tag team teach, use panels, workshop formats, problem based learning – whatever falls within the CME provider’s allowances for presentation/teaching/learning pedagogy.

    If you team up with others in your field locally in submitting topics, you may have more success in that the CME provider will want to provide where there is market share to be had.

  10. Steve, excellent post. Unfortunately, I agree that “one has to blaze an independent trail: obtain one’s own specialized training, recruit patients outside of the conventional means, and … charge cash.” Psychiatry does a poor job justifying itself as anything more than a prescribing guild. Moreover, in the mind of the public and many professionals, psychotherapy too now follows the drug metaphor: specific treatments prescribed for diagnosed conditions. Patients and insurers reasonably ask why they’d buy this commodity from a relatively expensive provider.

    Traditional psychiatry combines psychodynamic insight and medication when needed, and is the opposite of a commodity. Exploring the meaning of taking a med, or how a naive gloss like “chemical imbalance” affects one’s self-image and one’s plans for the future, is only cheapened by calling it a “value-added service” or “one stop shopping.” “Trauma, addiction, and grief” are mind-body problems of the highest order. Doing a good job in this realm takes time and therefore money, but the issues are too subtle and individualistic to appear on the radar screens of insurers or diagnostic manuals.

    In addition to representing a dying breed of old-fashioned psychiatrists, I also chair my medical center’s CME committee. I underscore what Dr. Cohen wrote above. It is bureaucratically cumbersome and often quite expensive to offer CME. Much CME is still funded indirectly by industry, so it’s not surprising that the bulk of it is devoted to psychpharm. It takes conscious effort to obtain balanced CME — the same “independent trail” you mentioned in your post — but it’s out there.

  11. MKSAP says:

    “In psychiatry, the vast majority of available CME credit is in psychopharmacology.”

    You can credit the drug comapnies with that one…deep pockets + high priced lobbyists = you MUST care about what we tell you to care about.

  12. […] to a manic episode.  We do “med checks,” as much as we might not want to, because that’s what we’ve been trained to do.  And the same holds true for other medical specialties, too.  Little emphasis is placed on […]

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