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"Residents feel like as though they've become a redundant factor in a patient's care," lamented psychiatry resident Diana Sanderson, M.D., at a workshop at APA's annual meeting in June in Toronto. Sanderson was describing the distress that more and more residents are experiencing over being "carved out" of psychotherapy training and education.
Sanderson, a third-year resident at Erie County Medical Center in Buffalo, N.Y., said that residents throughout the U.S. are frustrated that "HMO's, managed care companies, and other health care organizations are deciding how residents are going to be utilized-or more frequently, not utilized-in patient care." How, she wondered, can residents gain the training necessary to become skilled clinicians when the availability of patients for whom they can provide psychotherapy is continuously cut back?
She laid the blame for this problem at the feet of the federal government and the insurance industry-the former for drastically cutting back the National Institute of Mental Health's stipend money and changing Medicare regulations so that reimbursement is dependent on a beneficiary's being treated while an attending physician is present for part of the session. The presence of a supervisor during therapy can have only a deleterious effect on the therapeutic alliance between the resident psychiatrist and the patient, she suggested.
Following the government's lead and spurred by the ascendance of managed care, insurance companies are jumping on the same bandwagon and more frequently prohibiting reimbursement when a resident provides treatment, she pointed out.
Sanderson was part of a panel of APA Glaxo Wellcome fellows who discussed the consequences for future psychiatrists and their patients of denying residents opportunities to learn about and provide psychotherapy.
"Our interactions with patients are clearly suffering," she said, adding that the trend toward refusing to pay for care delivered by residents is "demeaning us in patients' eyes."
Andy Shapiro, M.D., a third-year resident at the University of Cincinnati, pointed out ironically that, because of being shut out of some opportunities for patient care, he has considerable time available to deliver that care, while an attending with whom he works complains of a six-week backlog of patients waiting for appointments.
A mail survey that the Glaxo Wellcome fellows conducted of residency training directors in psychiatry last year illustrated the frustration the panelists expressed. While 97 percent of the respondents said that their trainees receive adequate exposure to psychopharmacology, 78 percent said residents got sufficient experience with brief psychodynamic therapies, but only 67 percent believed that their residents graduate with sufficient experience with long-term psychotherapy patients.
Lamentable as the shifts in the training focus of psychiatry residencies may be, "we are never going to return to the old days," noted James H. Scully, M.D., the workshop's discussant. For decades, medical training in the U.S. has relied on a complex system of funding and reimbursement, but now that a few parts of that structure have been changed, "the whole system is out of equilibrium," he pointed out.
Scully is chair of the psychiatry department at the University of South Carolina medical school and a former deputy medical director of APA and head of its Office of Education.
To adapt and prosper in the face of these shifts, one critical task now confronting psychiatric educators and training program administrators "is to identify and define the specialty's core skills, such as the psychotherapies," and then devise ways to pay for training in those areas. From the medical establishment's point of view, the new funding strategies may not work as efficiently as the ones in place for so many years, but administrators have no choice but to devise alternatives that make sense now that the health care world has changed, he suggested.
Scully also called on psychiatrists to "think about the power of the neuroscience revolution" and how it will exert an increasingly powerful influence over psychiatric treatment and thus how future psychiatrists are trained.
Sharing the dismay of the residents on the panel, Scully dismissed the managed care industry's claims that by restricting reimbursement to board-certified physicians, they are guaranteeing that their beneficiaries will receive the highest quality care possible. "That's just a marketing ploy," he said, that the companies use to sell their networks of physicians and facilities to employers shopping for health coverage for their workers.
The Canadian system for training residents conspires to limit learning experiences of young physicians far less than does the one south of its border. In Canada, explained McGill University psychiatry resident Karine Igartua, M.D., a facility is eligible to be reimbursed for resident-provided treatment as long as the patient knows who the supervisor is and that physician is on site and available to the resident. Typically, the resident and attending may greet the patient together, she explained, and then the attending will leave, permitting the resident to provide treatment.
"This system works fine in the emergency room, but it's not quite so easy" when a resident is conducting psychotherapy sessions, she noted.
Supervisors are also allowed to bill for direct supervision of residents, but not for didactic teaching.
Residents are salaried, with their salary set and paid by the provincial health ministry and funneled through the hospital.
Though free of some of the serious obstacles impeding resident training in the U.S., all is not rosy in Canada either, Igartua added. Provincial governments, which administer and set policy for most of Canada's health system, have been cutting back on the numbers and salaries of psychiatrists and other physicians in response to reductions in health care budgets. The results of these actions include rapidly lengthening waiting lists for appointments, service cutbacks, and, in some provinces like Quebec, overworked psychiatrists with less time to devote to supervising residents.