The modus operandi for most American psychiatrists—and a basis for their identity—has long been private practice. Sigmund Freud and his colleagues were private practitioners. Now about 50 percent of us consider ourselves to be in private practice, while many more maintain a part-time private practice. Nevertheless, this number is in steady decline, primarily because of changes in health care financing.

Managed care and to some extent governmental agencies such as the Health Care Financing Administration challenge all of medicine and strike ultimately at the very quintessence of private practice and of our profession: the doctor-patient relationship.

This dyadic alliance has become a triad, increasingly dominated by obtrusive interlopers. Determinations about fees but also such clinical decisions as who is admitted to hospitals, the nature and quantity of psychotherapy sessions, medications that can be prescribed, as well as which " provider" and what discipline provides services are increasingly determined not by the physician and patient, but by administrators of the burgeoning health care industrial complex.

Yet despite the maelstrom of change, most of us are thriving and happy with our work. Some function exclusively outside of managed care contracts, others practice primarily within the parameters of managed care, while most of us do both. Still, change has affected not only the psychiatric private practitioner but all of psychiatry.

The Committee on Private Practice is part of APA’s response to the changes. The purpose of the committee is to (1) raise, discuss, monitor, and present opinions for action by APA on issues relevant to private office practice; (2) identify resources among and for the membership and serve as an information center regarding APA’s activities on issues of concern to the private practice constituency; and (3) increase coverage of private practice activities and issues in APA publications. We offer a scientific workshop on private practice issues during the APA annual meeting.

Development and sustenance for private practice committees at the district branch level is another project. To that end, we sponsor a luncheon for district branch representatives at each annual meeting. Two years ago we sponsored a debate at the district branch luncheon on whether to establish a separate private practice committee for those who worked outside of managed care and another for those who worked exclusively with managed care. The conclusion was that we needed one inclusive committee to represent both dimensions since we need to talk with one another and because many of us work in both systems.

We also work to increase collaborations between private practitioners and residency training directors so that practicing residents receive seminars on opportunities and techniques for starting or joining a private practice.

We have also developed a liaison with the World Psychiatric Association Section on Private Practice to learn from and commiserate with our colleagues abroad and to share experiences. Interestingly, since managed care has virtually saturated the American market, now, like McDonald’s hamburgers, it is seeking to sell its products abroad.

Recently, we established a mentoring program so that early career psychiatrists or others with questions about establishing or maintaining a private practice can be connected by telephone to a member of the committee for an exchange of ideas. We can be contacted through the APA Helpline at (800) 343-4671.

The Committee on Private Practice concluded that there are basic, essential ingredients within the traditional private practice paradigm that merit preservation. To that end, we have undertaken a project to identify and describe them. Some ingredients are more valuable and durable than others.

Issues that are emerging include primacy of the doctor-patient relationship for clinical decision making; freedom to work within the highest scientific and ethical principles of the medical profession; opportunity for the doctor and patient to have a complete, accurate, and useful clinical record whose confidentiality is securely protected; choice for both doctor and patient to determine with whom they work; capability to sustain the continuity of the doctor-patient relationship; autonomy to serve the patient’s best interests without conflicting economic incentives; double-agent employment dilemmas or other conflicts of interest; responsibility to practice to the highest clinical, ethical, and business standards as established and monitored by our profession; and the fee-for-service system.

Private practice has been and remains essential to all of psychiatry. The values and practices that sustain it are in many ways the sine qua non of our very profession. The Committee on Private Practice is one attempt to provide a forum for these issues. We will also collaborate with Psychiatric News on coverage of issues that primarily impact private practitioners. As psychiatrists, we excel at understanding and helping others. Nevertheless, we also need to discover our own voice so we can share our wisdom and our puzzlement, in communion with our colleagues, and to help ourselves as well as our patients. I welcome any suggestion you may have for private-practice topics you would like to see covered in future issues of Psychiatric News.