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I know I’m getting older. My view of this world has changed. I often listen to Gerry Mulligan, Ella Fitzgerald, and George Shearing because they made fine music, but also because they remind me of a time when life seemed forever sweet. In contrast to such a pleasurable pursuit, however, is the experience of practicing psychiatry in the 1990’s - which has become anything but sweet! I see too many of my colleagues making practice decisions based on what is best for business rather than for patients.
Last week I dropped the last huge managed care company with which I had participated - it was one of the ridiculous "form-filling-out" variety. The experience of removing this burden is like trying to rid my soul of some weird cancer. I wonder if I will survive financially. I have a son in college and a daughter in high school! But I feel that I have to draw lines in the professional sand. I stopped doing any hospital work two years ago and haven’t accepted medication samples from drug companies for far longer than that.
You might think I’m "nuts" or out of step with the times. But I think I’m preserving my soul. Every time I pull back from the pharmaceutical, private hospital, insurance, or contemporary medical industries, I feel better and believe it’s best for the patients who choose to consult with me.
My psychiatric practice philosophy includes negotiating fees with patients and discussing the evaluation and treatment process myself. The process of obtaining a psychiatric history for me involves listening to every prospective patient’s symptoms in the context of his or her life story, and this involves at least one or, in some cases, a series of hours. How many diagnoses are missed as a result of 15-minute evaluations and 10-minute follow-up visits or because the entire diagnostic process was delegated to a "therapist"? The professors who taught me what they knew of psychiatric practice believed that successful treatment was grounded in a collaborative and amiable working relationship with the patient - not in confrontation or predetermined treatment limits. How many of us have forgotten these principles or perhaps were never even taught them?
The prospect of receiving financial "crumbs" from the private hospital and insurance industries appears to be changing psychiatric practice styles and professionalism. If we psychiatrists give up our professional identity, how can we then take a position in the debates over who practices psychiatric medicine? If psychiatrists delegate interactions with patients - including supportive explanations of the disease process, management of the treatment program, monitoring of the mental status, and discussions of self-defeating behaviors - to nonpsychiatrists, why should we be surprised when patients, politicians, and other policymakers no longer support us?
Many other people maintain that they have the skills to do our job. I wonder whether psychiatrists have the courage and ideals needed to address critical practice issues in the public debate over our future and that of our patients. Where are the voices of our leadership, our paid consultants, our local chapter organizations? Are the important decisions about the requirements of good psychiatric practice being made at all? I regret that it often seems as if we’ve set aside our patients in favor of the business needs of managed care and private hospitals!
Dr. Williams is in solo private practice in Macon, Ga.