By Craig W. Maumus, M.D.

The early part of this year finds APA members continuing to search for signs of the direction in which our profession is headed. The game rules have changed. The players have changed teams. One may ask, "Are we still even playing the same game?"

Former Central California Psychiatric Society president Allen R. Doran, M.D., asks "Where Are We Going?" in his front-page article in the winter 1997 issue of the Central California Psychiatric Society Newsletter (Sam A. Castro, M.D., editor).

"Each of us must make personal decisions about practice in the current morass of health care and decide how to navigate the problems of American medicine and the U.S. health care system. The historical course of medicine and current health care trends in our country are not compatible, or even remotely convergent," Dr. Doran maintains.

Psychiatry--where cost-containment efforts have forced a shift in care to nonmedical professionals--has been affected by the changing landscape more than other medical specialties, he suggests. "We also see increasing reliance on primary care practitioners to diagnose and evaluate the appropriate treatment for mental illness. In California, we face continued attack on our exclusive right to prescribe medication or work in hospitals, the very backbone of our education.

"On the positive side, patients are increasingly sophisticated and are realizing that different types of treatment for mental illness, offered by various psychotherapists, lay counselors, and even unlicensed therapists, are sometimes unproven and even harmful. They look to our profession for evaluation of safe and effective treatment. The reliability of our diagnoses has now been shown to be equivalent to that in the rest of general medicine. . . .

"So where are we going? Fewer and fewer medical students enter psychiatric residencies--only 3 percent of graduating medical school classes each year. . .and all those who consider psychiatry as a specialty see increasingly more disciplines practicing psychotherapy. These medical students wonder what it means to be a psychiatrist and what the future will bring. If we allow cost-containment (managed care) and political forces (Congress, other therapists, interdisciplinary struggles) to dominate our thoughts, we could, in effect, be left with the spoils of our struggles. This could mean a reduced role or even elimination of our specialty. . . ."

Dr. Doran remains optimistic about our future, however, if we are proactive during this time of change and stick to our medical roots. "We need to be the best psychiatrists for our patients, as well as the best physicians. This is particularly true with those who have chronic mental illnesses. How many of our patients with schizophrenia get the best nonpsychiatric medical treatment (diabetes, hypertension, etc.) from us? We are physicians first, but we are in a specialty that is increasingly complex and demanding further subspecialization. While I am a strong advocate for increasing psychiatric training for my primary care colleagues, I also recognize that psychiatrists are in a better position to be the coordinators of care for patients with psychiatric disorders. . . .We are truly the champions of the mentally ill. . . . Let us be proactive, retain our medical roots, and move forward together."

Another writer attempting to make sense of the current changes is Paul Pressman, M.D., editor of Westchester Psychiatrist. In an article in the winter 1997 issue of that newsletter titled "The World Turned Upside Down: New Year Message," he writes about the chaos he sees in today's practice of medicine.

" 'All the forms you need to be successful,' promises a beautifully produced color catalogue. In its pages, artfully placed like so many pinups, are photos of volumes of CPT codes and treatises on sparring with managed care companies. Buy these manuals and your success is assured--a success determined by a physician's ability to name and number illnesses and symptoms and send a bill by computer. What has happened to Medicine?

"There is a painting of a crowded room. . .but it is so strange. Everything in it is upside down, including a bird in its cage. Its title is: 'The world turned upside down.' In our topsy-turvy world, physicians may well be chosen for their coding ability rather than their interest in healing. Is a physician a bureaucrat who knows how to 'work' the system? Is truth a lie. . .self-interest compassion. . .or greed generosity?

"Not long ago, medicine seemed not to be standing on its head. Starting out was scary yet wonderful. Having completed my residency, I was an Army psychiatrist stationed in Frankfurt, Germany. In our clinic and on our ward we saw 'ordinary people' in terrible situations, not unlike my later private and institutional practice."

Dr. Pressman goes on to describe some of the interesting clinical cases he saw in the Army and then explains why we should revisit the past for reasons other than nostalgia.

"Near drowned by the nonsense that floods our field, forced to make terrible compromises in order to make a living . . . .We must remind ourselves just how marvelous it is to be a psychiatric physician. In a world that may reward cunning accounting skills, salesmanship, and hypocritical cynical decision making, much more than humanity, breadth of understanding, and just plain warmth and decency. . .think of your patients now and in the past to keep your bearings. . . . Let's treasure the good of our work and the nobility of our profession. . .then what is shallow can never be profound. . .what is bad can never be called good. Oriented by our faith in the value of our work, our personal world will be set right."

(Psychiatric News, May 16, 1997)