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By Craig W. Maumus, M.D.
The newsletters from our district branches continue to reveal a common theme: substantial concern and anxiety about our practices and our profession.
Typical is the article written by Richard J. Thurrell, M.D., editor of the Wisconsin Psychiatrist. In a fall 1997 editorial titled "Change, Controversy, and Worry Ripple Across Our State Highlighting Need for Medical Unity," Dr. Thurrell asserts, "Changes in health care systems have caused a variety of worrisome challenges for psychiatrists and other physicians" in his state and throughout the U.S.
"Solo practitioners and those in small groups or single-specialty clinics have been feeling that they are endangered species. Larger groups also feel endangered by competitive pressures-not for care quality but for revenues and employee contracts. The small- and medium-sized fish wonder anxiously when they will be swallowed by the big fish and how much it will hurt. The larger organisms wonder if and when they'll have to make disadvantageous deals with the giants of the 'industry'….
"The adversarial and competitive medical zeitgeist of our times seems also to have had impact in a broader way, even when a two-party personal dispute is absent. Colleague has withdrawn from colleague partly from the need to work harder and longer, but more importantly because of competitive suspicion. Practice groups, despite continuing merger mania, have become insular, meanly competitive, and suspicious of one another. Old friendships have been strained or crushed in many instances...."
Dr. Thurrell reminds his readers that despite these sometimes profound differences among physicians about what the evolving health care system should look like, "we need to recapture dedication to our basic purpose, however that purpose be achieved. Our renewed commitment must be based upon preservation of the primacy of seeking the best possible medical and psychiatric care for all citizens as implemented via the doctor-patient relationship...."
As a profession, physicians "must seek unity of purpose in strengthening our weakened commitment to optimum patient care via the doctor-patient relationship. We need to talk, act, and, if necessary, argue about ways to pursue our basic goal. Once we've reiterated our mutual commitment to patients and our relationship to them, and disagreed more vigorously on modes of pursuit of these overall goals, we might more comfortably rediscover our collegial friendships."
Once that goal is achieved, he adds, then it will be the appropriate time to engage in the different points of view that separate physicians from each other.
Dr. Jerome Schnitt, president of the Connecticut Psychiatric Society, also writes about change and uncertainty in his column in the winter 1998 issue of the Connecticut Psychiatrist (Simon Epstein, M.D., editor). He identifies an "uncertain future" as the most difficult issue that Connecticut's psychiatrists now face.
"Our professional autonomy, our treatment technologies, our ability to earn a living, and our very identities are changing rapidly," he points out. "This is a fundamental culture change: one we did not vote for or solicit. These changes come from the outside, but they aren't fading away. They have changed the way we can conduct ourselves if we accept any third-party funding to care for our patients."
To help us put these changes in perspective, Dr. Schnitt draws up an example from history-the potters in Delft, Holland. Once these respected professionals held a near monopoly on fine pottery. New members of the guild had to train for years.
"Then came a period of rapid change. The English developed a method of mechanized throwing, the Italians put talented artisans to plate-painting only, and the Germans developed large coal-fueled kilns capable of firing thousands of plates at once. These changes meant that lesser-trained potters could, with business funding, turn out mass-produced wares of pedestrian but serviceable quality, at a much lower price. At first the master potters noticed only a little change in their business. They examined the mass-produced plates and pronounced them inferior, noting that the informed public would not buy such merchandise. Within a few years, however, the market for the Guild's wares dropped dramatically as larger manufacturers streamlined and diversified their production."
How the Dutch potters' story turns out is surely apparent, Dr. Schnitt observes. "The majority of the public settles for mass-produced plates. The number of independent potters is minimal, the number of salaried potters is moderate, and the majority have to move to other work." All the potters were forced to adapt to the new shape of their profession, though none would have willingly chosen to do so.
Dr. Schnitt reminds us, "Failure to actively adapt makes us all vulnerable to repeat old responses. We need to figure out how to deal with our current situation more effectively than we have, or we will recapitulate old issues."
He then paints a more detailed picture of how managed care has affected our profession, just as the changes described above reshaped the Dutch pottery business.
"Again, we all know the results. The managed care industry has had enormous impact on the work of psychiatry. No one knows for sure what the next generation of management approaches will be," he notes, "but we know from our work that the most effective means of adapting is to learn more: identify the problem, broaden the skills and understanding through education, render unto Caesar what is his, and fight battles we can win. Learning about the new clinical techniques and methodologies enables each of us to choose the most cost-effective therapeutic treatments for our patients. Some of us will be able to work full-time a là Delft, but most of us won't."