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By Lauri R. Robertson, M.D., Ph.D.
A psychiatrist entering practice today will have to navigate a massive transition, one made even more difficult if he or she chooses to begin a private practice. One forward-looking option to deal with the upheaval is to join a multidisciplinary group that offers comprehensive mental health services. An alternative-the one I chose and will argue is forward looking in its own right-is to open an old-fashioned, solo private practice.
This may seem like a radical notion today, but since I began practicing in the early 1990's, other options have become far less appealing or even unavailable. Provider panels have closed; insurance companies impose restraints on psychiatrists in HMO's, preferred provider organizations (PPO's), and other organized systems; and mental health carveouts have brought intrusive "micro-management" that severely limits patients' access to their benefits.
The concrete aspects of opening a solo practice are simple. You need an office, two chairs, a telephone, malpractice insurance, and a shingle. An inexplicable pleasure comes with the acquisition of these bare necessities. Office space with mental health professionals or other psychiatrists can provide quiet camaraderie. Naturally there's an advantage to opening a practice in the community where you've trained. But there's also advantage in moving to an area with fewer clinicians.
The details of practice-whom you will treat, work hours, coverage arrangements, whether to have an answering machine or a service, method of record keeping, billing policies-are up to you. A flexible fee schedule is both practical and ethical.
At least initially, you're likely to need a source of income. A part-time salaried position (possibly with health care benefits!) is ideal. Solo practice is intense, exhilarating, and heartening, but it's hard, lonely work. The structure and collegiality of an institutional job can be a welcome counterpoint. A hospital or clinic environment also offers opportunities to establish a good reputation among colleagues and can provide a referral base.
And you will need patients. A first step is to send a practice announcement to everyone you can think of in the mental health and medical communities. Educational and religious organizations are also good referral sources. You may want to indicate your areas of expertise but, outside of a research setting, there's a certain artificiality to diagnostic specialization. Most people come to treatment with a blur of symptoms and issues; some measure of depression, anxiety, and relationship difficulties is ubiquitous. You're likely to receive inquiries from non-M.D. therapists seeking to refer patients for medication consultation. These may initiate fruitful collaborations, but it's wise to clarify each other's expectations before embarking. Make it a point to thank referring professionals.
A major problem under managed care is the lack of access to psychiatrists. Fewer and fewer patients who use insurance can freely choose their treaters. Nationally, enactment of "any willing provider" laws is proving to be a slow, uncertain process. Seven years ago I followed what was then sound advice: "Join everything you can." I belong to 17 assorted PPO's, independent practice associations (IPA's), behavioral health care companies, hospital medical staffs, medical societies, and government insurance plans, most of which are in nested relationships with others.
At present, nearly half my referrals come via these affiliations. There are, however, several caveats. Many panels are closed to new, individual providers. Some have 800 numbers instead of lists and refer largely to targeted practice groups, which may have capitated contracts. IPA's, however, are also positioned for capitation. "Join everything you can" is probably still good advice, although there may be diminishing return for the effort.
But the superordinate problem is treatment constraints. From the current managed care perspective, psychotherapy is ethereal, expensive, and largely expendable. Considerable paperwork, voicemail vigils, and even argument may be needed to obtain approval for it. In the future, payment for psychotherapy may be almost entirely out of pocket.
At times I've tried to think in terms of tailoring treatment to a patient's insurance, but I felt I was advocating limping treatment. When clinically indicated, I now discuss the possibility of ongoing psychotherapy irrespective of a patient's coverage. So far, this has been acceptable within a managed care framework. The patient and I may review his or her financial situation and my sliding-scale fees. Whether or not we continue, there's been an honest exchange.
If you feel strongly that psychotherapy is important for a patient, say so and why. It's essential to maintain the integrity of our deepest convictions beyond a timidity engendered by managed care's influence. Making psychotherapy widely available does, however, require a willingness to earn less money than you otherwise might.
For reasons of privacy or freedom of choice, many patients elect to pay for psychotherapy themselves. Some, who initially feel unable to pay for further treatment, can rearrange their priorities and return at a later date. It's ironic that for a majority of patients, the "natural history" of psychotherapy is relatively brief. I've found that those who stay more than six months are likely to stay more than a year. A long-term psychotherapy practice thus builds slowly within a general practice. Over time, the most enduring source of referrals will be your patients themselves.
Unfortunately, after the pedagogy and cautious promises of residency, many of us still need to be convinced-psychotherapy really works! People come to treatment to feel better. But many want to talk and, having begun, gain a locomotive sense that it can lead to feeling better in a deep and abiding way. They want to understand and alter painful, baffling patterns of experience and find voice for their inner lives. Common wisdom will quickly point beyond what managed care offers.
I'm increasingly impressed by how long it takes to become a masterful psychotherapist. There's no substitute for sitting with many different patients over time. Consider buying supervision or forming a peer supervision group, which may become an enduring support network.
In summary, there is no simple "how-to" of private practice in the 1990's. I hope it's evident that various blended models exist. A solo practitioner who belongs to a PPO is essentially part of a group. An interdisciplinary group may permit autonomous contracting. There are salient choices to be made about the extent of one's involvement with managed care, each with advantages and risks.
Also, I strongly believe it's an important time to take advantage of public forums by giving talks, for example, or writing for the lay press. These are excellent platforms for articulating the value of our work.
Dr. Robertson is in private practice in New Haven, Conn., and on the clinical faculty of the Yale School of Medicine psychiatry department.