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By Craig W. Maumus, M.D.
Perhaps it is part of the Millennium Malaise, but many authors of district branch newsletter articles and columns continue to wrestle with the difficulties of the rapid changes going on in the delivery of health care in general and psychiatry in particular. The angst simply will not go away.
In her President's Message in the Winter 1998 issue of the Kentucky Psychiatrist (Steven Lippmann, M.D., editor), Dr. Peggy Stephens wonders just who is responsible for the "patient/client, sort-of insured person."
"These days, I find this question quite emotionally charged, and at times downright frightening," she admits. "Based on my medical training, this person's care becomes my responsibility the moment [he or she becomes] my patient. The humble recognition of the privilege of serving this role and a commitment to this relationship have been the cornerstones of good medical care. Our responsibility to the patient has never changed; but rather, the authority to carry out that responsibility has been undermined. . . .
"The profit-driven strategies of the managed care and insurance industry are trying to reduce that relationship into nothing more than a business deal. . . . Managed care even gave us new titles to help dehumanize and generalize the relationship; the physician is now the provider, and the patient is the client/insured. We all have our roles in this business relationship, with the patient wanting to receive care, the physician wanting to provide care, and the managed care company generally providing the message something like this: 'You know I can understand your problem, but we just can't help. . . . Of course now we cannot make decisions about medical care, but only about medical necessity as determined by the policy stipulations. . . . Have you tried the 12-step groups, the school system, or other community services' (or anything else that doesn't cost the managed care company anything)?"
Dr. Stephens deciphers the agenda behind this cost shifting. It took the managed care companies little time, she notes, to recognize "that certain subpopulations were the most costly. . .and therefore targeted them for cost reductions. The obvious problem that won't go away, however, is that they are the most costly because they are the sickest and most needy. Clearly the situation will only be compounded by this strategy of giving these groups less and less."
With all her years of comprehensive training, Dr. Stephens points out, it never occurred to her that a business degree would be crucial to understanding how to practice medicine. "Now, by necessity, I spend a significant percentage of my continuing education reading to understand the business side of practice. It is a very uncomfortable and sad situation, but I live in the same world as my patients/clients/insured and must be knowledgeable in order to adapt and position myself to effectively fight for the importance of the doctor-patient relationship.
"The forces that are pulling us are tremendous and frequently at odds, creating confusion and anxiety about what is our responsibility and what is the right thing to do. I find asking myself two questions helpful. First, is this the kind of a care I would want for my mother, my brothers, my child? And secondly, would I feel good about telling someone I respected what I did and why I did it?"
But managed care is only one of the changes we are having to deal with these days. Legislative battles over parity and psychologists' prescriptive privileges may likely produce other changes in medical practice we will need to reconcile within ourselves.
Dr. Saundra Maass-Robinson, editor of this year's Newsletter of the Year (among the large district branches), the Georgia Psychiatric Physicians Association Update, writes about these changes in her November/December 1997 From the Editor column.
"As I prepared this edition of Update and reflected on its contents, I was reminded again of how tired we must all be of these continuing battles. Some of us (and our colleagues in other specialties) are giving up the fight and moving on to other endeavors. A local TV station recently did a news special on this very subject. . . .
"I met recently with a number of state legislators, and they reiterated the same request-find a way to compromise (on legislative issues or the legislature will do it for us. The disheartening aspect of these conversations is the continuing perception that somehow we, the physicians, are the problem, or that at the very least we have created the problem. Our motives have been interpreted as self-serving rather than as a true concern for patient care. Our reaction to this, unfortunately, is often a defensive one, and once again we find ourselves in battle. . . ."
Dr. Maass-Robinson's explains that her concern is what psychiatry and the rest of medicine will look like when these battles finally end.
"Nature abhors a vacuum. Eventually order will emerge where chaos now exits, but at what price? Do we continue to fight because we hold on to a way of practicing medicine that no longer exists? Are we self-serving, not solely for monetary reasons but because of our romantic vision of the way this profession used to be? Are we unwilling to relinquish that way of life, electing to quit altogether, rather than adapt? I wonder if the dinosaurs felt an angst similar to ours? . . . .
"At this time I am reminded of the words of the Native American Chief Joseph of the Nez Perces Nation, 'I am tired. My heart is sick and sad. From where the sun now stands, I will fight no more forever.' With those words an entire nation's way of life was changed forever. I wonder if we can keep the same from happening to ourselves?"