The D.B. Dispatches column in the March 7 issue quotes Kenneth N. Weisert, M.D., and Stephen Dilts, M.D., to the effect that, if we get our priorities in order, we can not only live with but also flourish under managed care. They offer no evidence for this, and their arguments are not persuasive.

Weisert claims that, if the psychiatric community can only demonstrate that we can take care of difficult patients "effectively and efficiently," we may be allowed to coordinate the work of other disciplines and define the scope of their patient-care activities. We can do these praiseworthy things, he suggests, because of the breadth and depth of our training and experience. He fails to note that we acquired these capacities before psychiatry was Balkanized into a mosaic that is less than the sum of its parts. Further, Weisert knows that managed care avoids difficult patients whenever possible because it is loath to pay what it costs to treat them.

Accepting, for discussion, Weisert's thesis--that a headless beast yearning for coherence will turn to psychiatry for guidance--what happens when the thinning ranks of psychiatrists broadly trained in traditional modes and ethics of clinical care disappear? The psychiatrists who would supplant us will have been trained in the "mini-psychiatry" favored by managed care and will be competent only in the narrow sector of the field they have been allowed to learn--perhaps how to treat only filtered patients. What, then, would they teach? Whom could they supervise; whom could they instruct?

Dilts, too, promotes our role as savior of hard cases; he has harsh words for those who would squander our hard-won expertise on routine cases. He, too, envisions a transcendental role for psychiatry and insists that "our special holistic diagnostic capabilities and overall sense of patient care responsibility are essential for a significant number of patients."

But how are psychiatrists of the future to acquire and transmit to other professionals this overarching conception of patient care if their own training and practice are limited to whatever the managed care "filter" allows them to see? How could they treat difficult cases if they had no experience with routine ones? They would be like surgeons trained to do only transplants and amputations. In traditional psychiatric training, one learns all too soon how easily a "minor" problem can become overwhelming and avoids the simplistic "major/minor" thinking. The old saw still cuts: "There is no minor surgery, only minor surgeons."

Both writers find a silver lining of leadership in the dark cloud of managed care; both are vague about how psychiatry will manage to be invited to lead lesser minions who, in their view, would care for "less complicated situations." Others, I among them, are not sanguine about this scenario. Even if psychiatry does become reconciled to working "in controlled settings without the freedom of the past" (Dilts), where is the evidence that mental health professionals from other disciplines will meekly submit to our "supervision," our "coordination," our "guidelines"?

And what about our ethical duty to give our patients the best care we can? How could we do that if we confine our own efforts to treating hard cases and advising other professionals? Partly through psychiatry's efforts, many courts and legislatures recently have removed the "gag rules" that stood between patients and psychiatrists. Other cracks in the "bottom line" mentality of health insurers appear daily, as patients and employers increasingly question the necessity of "cost control at any cost." In the face of these inroads, why should we now retreat from our commitment to vindicating the trust patients place in us to play fair with them and give them our best? Perhaps we shouldn't retreat.

As long as managed care achieves cost reduction through denial of care (cutting "medical loss"), we can't effectively assert our patients' best interests, no matter how well trained or deeply experienced we are in managing "difficult cases." And as long as psychiatrists help care managers skimp on our patients' needs, it will look as if Pogo was right.

Douglas Sargent, M.D., J.D.

Birmingham, Ala.

(Psychiatric News, May 16, 1997)