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The discussion at an APA annual meeting workshop in May showed there is little disagreement that the psychodynamic aspect of treatment remains a critical component of psychiatric education. It appears, however, that despite the fears of both new and veteran psychiatrists that it may disappear from training curricula, the jury will be out a long time before any consensus emerges on how large a part it should continue to play.
One of the educators at the workshop in San Diego, David Bienenfeld, M.D., director of residency training at Wright State University in Dayton, Ohio, cautioned that "even in a worst-case scenario in which psychiatrists are not reimbursed at all for psychotherapy," psychiatrists cannot afford to sacrifice the teaching of psychodynamics. Without an extensive understanding of psychodynamic concepts, future psychiatrists will lack a valuable diagnostic tool and a crucial element of their profession's science, he said.
The panel member with the greatest stake in the debate, Eva Szigethy, M.D., a resident at Case Western Reserve University, stressed that despite changes in the health care system, "residents very much want psychotherapy to be part of their professional identity."
Decisions to relegate training and education in psychodynamics to a minor component of residency training "will have serious implications for recruitment and satisfaction" of psychiatry residents, she said, and contribute to a devaluation of the relationship between psychiatrists and their patients. There is no way other than conducting psychotherapy for a psychiatry trainee to gain the experience with patients he or she needs to become a competent therapist, Szigethy noted.
Warning against a headlong rush to align psychiatry training with the needs of the managed care industry, workshop chair Ronald Martin, M.D., a psychiatry professor at the University of Kansas and chair of the APA Committee on Medical Student Education, predicted that the pressure by managed care companies on psychiatry training directors to marginalize psychotherapy training and to teach how to treat every illness with a pill will eventually "backfire in the managed care industry's face."
Psychiatry has an obligation, Martin said, to educate the industry about how important it is for treatment success that psychiatrists retain the tools that help them achieve a full understanding of mentally ill patients, and this means extensive psychotherapy training.
Despite the devotion of managed care to pharmacotherapy, "it is hard to gauge its efficacy outside the context of a rich and meaningful doctor-patient conversation," Bienenfeld added, and this crucial element of psychiatric treatment, which depends on an understanding of psychodynamics, will be lost if the next generation of psychiatrists is capable only of prescribing medications.
If training directors fail to adapt their programs to the environments in which their residents are going to practice, however, they will find themselves turning out graduates who are inadequately prepared to compete for ever-scarcer health care dollars, pointed out Jeffrey Akman, M.D.
"We do residents a disservice if we don't adequately train them to practice in a managed care environment. Programs must provide training opportunities in HMO's, for example, and need to put more emphasis on various types of short-term psychotherapy," said Akman, who is an associate professor of psychiatry and director of medical student education at George Washington University medical school.
"Residents must come out of their training ready to practice, rather than emerging from the womb of their program not knowing how to treat patients in four outpatient visits," a limit psychiatrists should be prepared for their patients' insurers to impose.
Lawrence Martin, M.D., of McMaster University in Ontario, described a Canadian residency curriculum that might prove useful in the U.S., even though his country's physicians don't have to contend with managed care. At his medical center, psychiatry trainees go through eight psychotherapy modules linked to different rotations, during seven of which the residents are trained in various forms of short-term psychotherapy. The eighth module provides experience in long-term therapy, and Martin pointed out that the program is beginning to increase the time spent on psychopharmacology education.
Bienenfeld suggested that training for "practice realities" will still be incomplete unless curriculum planners also include opportunities for residents to learn about vital areas such as practice financing, marketing, reimbursement issues, "models of accountability and outcome measures that cut across the biopsychosocial spectrum," and team collaboration skills--"it's arrogant to think that psychiatrists will always be leaders of the mental health team," he added. The residents in his program at Wright State can even gain experience as managed care reviewers, "a vital part of training for the real world."
Case Western Reserve has also recently restructured its residency program to reflect the impact on academic medical centers of changes in the way health care is delivered and paid for, Szigethy noted. It took "a two-year battle," for example, to resolve the troubling credentialing issue, but "we were eventually able to get our hospital-owned managed care company to provisionally credential our residents as long as they were receiving supervision, even indirectly, from a credentialed attending provider," she explained.
They were also able to agree on a solution to the problem of how the medical center could be reimbursed for care provided by residents without reducing the involvement residents need to have with patients. They were searching for a way to operate with stricter visit limits while still being able to provide trainees with sufficient professional experiences and education to allow them to grow professionally, an issue that did not exist under a fee-for-service training system.
Administrators and training supervisors agreed that "however much money was authorized to be in the pot for a particular patient could be paid out so that residents could have a few more sessions with that patient. The money was distributed so that there would be a little less reimbursed per patient visit," thus allowing residents to gain the experience that comes from following a patient over several visits.
Another adaptation that Case Western Reserve instituted for two Medicaid HMO's where residents receive outpatient training freed up money for additional treatment visits by reimbursing residents at the rate for nurse practitioners.
"The nice thing in both these situations is that our outpatient clinic gets close to 100 percent collection of fees, which is far more than was received under the old system, when more per visit was charged," she pointed out. Both residents and administrators seem pleased with the changes, she added.
(Psychiatric News, July 18, 1997)