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Talk Is Cheap

October 9, 2011

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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