By Craig W. Maumus, M.D.

Psychiatrists around the country continue to express anxiety over their futures. Are we prepared to practice our specialty as we were trained to in the years ahead? And what role will the psychiatrist of the future play in the delivery of health care to those with mental illnesses? In reviewing district branch newsletters for APA's Newsletter of the Year contest, I came across a couple of articles whose authors express interesting perspectives on these important questions.

In the April 1996 issue of Spectrum, the newsletter of the Indiana Psychiatric Society (Kenneth N. Wiesert, M.D., editor), then IPS president Stephen R. Dunlop, M.D., in a column titled "We Will Survive," contemplates several issues related to the future direction of our specialty.

"More and more patients will come to us after passing through a filter," he writes. "This may be a primary care physician or some other gatekeeper. For psychiatrists working with a capitated product, this may be a mental health worker supervised by the psychiatrist. I think that there is no one else in a position to be on the other side of the filter and take care of the difficult patients. For psychiatrists, the important question may be their ability to show they can do this work effectively and efficiently. I think we can and do."

Dr. Dunlop suggests that psychiatrists will be spending more of their time coordinating the activities of other clinicians and will be called on to develop guidelines that ensure top-quality pharmacotherapy and psychotherapy.

"For pharmacotherapy, the question of timely assessments that lead to good second- and third-line treatments for nonresponders will be very important. For psychotherapy, the ability to define goals and techniques is something psychiatry can do best." He also stresses that psychiatrists can play a critical role "in defining the scope of care for other professionals" who treat mental disorders.

Dr. Dunlop ends his view of the future on an optimistic note, observing that while "there have been and will be dislocations and disappointments" for some psychiatrists, "we have the opportunity to come through this still the most important and valuable profession in the treatment of the mentally ill. We are already better respected within medicine. We have shed some practices that had dramatically escalated costs with little documented benefit. . . . Our costs for episodes of treatment have come down dramatically. Third parties finally seem to be paying some attention to the quality of psychiatric services. Some psychiatrists have begun to create systems of care under our own direction. I hope that you can share my optimism. . . ."

In September the Colorado Psychiatric Society published an article in its newsletter (Drs. Claire Zilber, Deborah Stetler, and Laura F. Michaels, coeditors) by Stephen Dilts, M.D., titled "Can Psychiatrists Adapt to Their Future?" Dr. Dilts is medical director of the Colorado Physicians Health Program and vice president of the American Academy of Addiction Psychiatry.

Pulling no punches, Dr. Dilts writes, "I am concerned about our future as psychiatrists and about our apparent inability to adapt to dramatic changes. It seems that a significant proportion of us want to preserve the type of practice that we have known in the past, despite the fact that things have already changed and that those practices no longer exist. I feel like Pogo when he observed that 'We have met the enemy and it is us.' "

"The self-indulgence" of physicians in the 1970's and 1980's led the health care system to the brink of bankruptcy, Dr. Dilts points out. Yet even though "we have been told this over and over again, we persist in wanting things to be the way they were. My worry is that organized medicine, including CPS and APA, has not addressed our future role in a manner that sells us on the prospect even if it means a cut in pay. . . .

"Certainly managed care must be worked with in order to preserve quality of care, but we are not going to escape from being managed. The days of psychotherapy ad infinitum are gone, and I'm not even certain that we can justify our role in the provision of therapy to an average case when compared with other mental health [clinicians] on a cost-effectiveness basis. I happen to think that we can in certain ways, but only in a new paradigm that actually is a return to the past.

"Our unique role rests in the fact that we are physicians and are uniquely qualified to consult on and treat more difficult cases in which the interplay of medication management and medical issues requires our expertise. There is no reason for any logical budget planner to pay for our long years of training and expertise in less-complicated situations, but our special holistic diagnostic capabilities and overall sense of patient-care responsibility are essential for a significant number of patients," Dr. Dilts emphasizes.

"I hear increasing dissatisfaction with our professional societies, and I don't think that it is because those groups have lost some imagined war with managed care. I think that it is because they have not led the way in helping their members adapt to a new era, the first step being to leave the past behind. . . . Private practice may continue to be available for those special practitioners who are able to attract paying patients, but the majority of us will have to work in a controlled setting without the freedom of the past. This kind of practice may be different from what many older psychiatrists have enjoyed, but it isn't necessarily bad.

"Many of us have worked in public hospitals, mental health centers, and private systems, all of which managed their care but didn't label it as such, and we have enjoyed such work. Managed care fellowships are being developed to train psychiatrists to work effectively in a managed context and to be able to work on the management side successfully. An increasing number of psychiatrists are spending part or all of their time in the administration of managed care; we can't afford to pretend that they are the enemies of clinicians. It is time for new collaborations."

(Psychiatric News, March 7, 1997)