 |
 |
|
|
Many articles have been written about the impact of managed care on our practices. Little has been written, however, about its impact on psychiatric education. This issue is finally getting some exposure as exemplified by two articles in our district branch newsletters.
Andrew F. Angelino, M.D., a fourth-year resident in Maryland, recently wrote an essay in that DB's newsletter (Lino Covi, M.D., and John Chapman Urbaitis, M.D., coeditors) titled "Managed Care-Managed Education," which brings the problem into clear focus.
"A funny thing happened on the way to work this morning," he writes. "An insurance company decided what all the psychiatric residents were going to learn."
Dr. Angelino says this premise occurred to him when it again came time to request an insurance company's approval to continue psychotherapy with a patient he had been treating for depression for several months. How, he wonders, "does one request that payment be authorized for treatment of resistance to a discussion about interpersonal conflicts?"
In reviewing this case with his supervisor and other teachers, Dr. Angelino noted that many of them "find themselves resorting to 'more efficient' medical models and 'critical paths,' all the while shifting the practice of outpatient psychotherapy into what resembles a hundred-yard dash rather than walking a mile with a patient." But, he observes, that is only part of the problem. He regrets that psychiatrists themselves "cannot. . .agree that more efficiency is needed--that some patients actually do better in the hundred-yard dash than the marathon. One of my more vociferous professors even retorted that his immediate goal for the patient was the alleviation of symptoms, and his long-term goal was the maintenance of that symptom-free state. He therefore concluded that he should be authorized to see the patient weekly for life. The insurance company reviewer begged to differ."
Dr. Angelino identifies three areas of psychiatric education that managed care has affected: "the length of inpatient stays, the number of outpatient psychotherapy sessions, and supervision of nonphysician psychotherapists.
"First, managed care has decreased the length of stay of patients in the hospital. In my opinion this is a move forward--the days of 200-day stays are over. . . . The problem arises when hospital length of stay is so short that it limits what a resident learns about how to care for patients. . . ."
On the matter of psychotherapy sessions, Dr. Angelino feels that "the issue in decreasing the number of visits for which a patient is 'approved' has influence on the psychotherapy itself, which is difficult for a novice therapist. The effects of putting a time constraint on the therapy practiced by a resident can be devastating. Residents are becoming adept at short-term, supportive psychotherapy because that is what they are given the opportunity to practice, but they remain ignorant of or impotent to the subtleties of the psychotherapeutic hour that often arise only after the first six months."
Lastly, he deals with the issue of psychiatrists having to supervise the nonphysician therapists who now have a greater clinical role thanks to managed care. "Just how does one teach a resident to supervise the therapy of someone who has been doing therapy with a particular patient for two years longer than the resident has been a doctor? He or she probably does not have the faintest idea of what it must be like to direct the care of a patient without delivering it. . . .
"To this quandary, I must again reply that clarity is the key. The resident who will learn to supervise well is the one that is supervised well, with focus on clarity of formulation and treatment process and goals."
Also contemplating the changes in psychiatric education is a member of the Michigan Psychiatric Society who has just initiated the column "Occasional Feature" in that DB's newsletter (Beth Goldman, M.D., editor) under the pen name of Pythi.
"Change, per se, is not a synonym for progress," writes Pythi, emphasizing that psychiatric education and training is an area in which change is not occurring for the better and should not be tolerated.
The pervasive use of gatekeepers means that by the time residents see a patient, that patient "will already have been given a (correct or incorrect) psychiatric diagnosis, and based on that diagnosis, treatment often will have been started. Optimal education would dictate that residents see patients before they are treated, so they can see the various syndromes before modification by treatment, especially if the diagnosis is not appropriate for the patient."
In addition, the government's new rule requiring that all billable treatment under Medicare and Medicaid be provided by staff physicians and not trainees "effectively precludes residents from assuming full responsibility for their patients at any time during their residency." Pythi is concerned that managed care companies may follow the government's lead and institute a similar requirement.
Finally, Pythi discusses what the content of psychiatric training should be. The author notes that "it would be expected that psychiatrists should do what they do best--diagnose and treat mental disorders, especially those aspects of diagnosis and treatment that require the expertise of a physician. That expectation is eroded not only by primary care treatment of more and more patients with mental disorders, but also by recent clinical, legal, and legislative efforts of non-M.D. clinicians to obtain mandated admitting privileges to hospitals, medication prescribing privileges, and larger and larger roles in the planning and delivery of all kinds of mental health care. Separate from the ultimate clinical and administrative outcome of these incursions, the question of what to teach future psychiatrists is complicated by the difficulty in being able to accurately predict what they will be doing. How much will attempts at cost savings, at providing care by the cheapest alternative, affect what psychiatrists do?"
Pythi offers three suggestions: "First, all entities that make money from the provision of health care should be required by law to contribute to the support of education. Second, for the benefit of the patient, access to specialty care must be reasonably unfettered and 'gatekeeper' physicians must not be unduly motivated to impede this. Third, those now in charge of the health care system must be mandated to guarantee the first two. As unpopular as it now is, there is no avoiding the need for government oversight. The inevitable alternative would be a clinical version of social Darwinism."
(Psychiatric News, June 6, 1997)