A recent front-page New York Times article described how most psychiatrists have abandoned psychotherapy. It featured a Pennsylvania psychiatrist who, assisted by his wife as office manager, worked a very large and efficient volume practice of medication prescribing. The doctor, in his mid-60s, had been trained in dynamic psychotherapy and felt regret at not getting to know his patients nowadays. But what else could he do? The new short-visit, medication-focused practice style was the only way he could protect the lifestyle to which he and his wife had grown accustomed.
When I have the opportunity, I counsel medical students and residents to start out in practice by keeping their “expense base,” i.e., their lifestyles, modest. Am I advocating asceticism? No, freedom. If a couple becomes accustomed to a lavish way of living—big house, expensive cars, clothes, jewelry, and the trimmings—it is extremely hard to go down. Therefore, when insurers or, increasingly, employers demand more productivity or decreased income, the choice is forced. The penalty for many colleagues is conscience pangs and perceived stress. They “cannot” practice the medicine they wish to and would feel good about. I have witnessed many physicians pay the price in stress-induced medical and psychiatric symptoms and disorders.
I make no moral judgment, but it is, in fact, a choice. And there are consequences in either direction. And few who follow the rancorous debates concerning healthcare reform think physician compensation won’t take a “hit” over the coming decade and beyond.
So, can psychiatrists still practice patient-centered care, taking sufficient time to carefully evaluate patients, to get to know them? And can we still practice psychotherapy? Of course we can. It’s a question of money. We can accept lower rates of reimbursement per hour from insurers—for at least a percentage of our time. We can do some “pro bono” work. Or we can return to the days of yesteryear and ask patients to pay “out of pocket.” There are choices. There are options.