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The front page of the July 17 issue of Psychiatric News states that residents are dissatisfied with their training, and that APA is losing membership. It should evoke little surprise that residents want to learn the full range of psychiatric therapies and that psychiatrists want to be able to employ those treatments.
The assumption that residents need to be taught how to treat patients based on current reimbursement schemes rather than sound clinical principles is short-sighted, morally wrong, and bad medical practice. At Delaware Psychiatric Center, where I am residency training director, the residents are not exposed to managed care, because practicing in managed care settings does not enable the resident to gain an adequate grounding in psychiatric practice: taking full responsibility for a case, treating the patient as a whole, establishing a therapeutic alliance, knowing how and when to prescribe psychotherapy and/or medication, and treating patients over the natural course of their illness. Teaching residents how to do half-hour evaluations, 15-minute med checks, and negotiate with claims reviewers are not skills that will allow our profession to grow, but are rather a recipe for our profession's marginalization and eventual demise.
In my private practice, I do not accept any form of payment other than fee for service. My practice, which consists of middle-class patients, remains as busy as it has been for the last nine years, even though managed care has grown exponentially in my area. This is possible because patients value quality treatment and are willing to pay for it. Billions of dollars a year are spent by patients directly for medical care with no third party payer involved, for example, dental care, chiropractic treatment, plastic surgery, etc. Minimizing the role of third-party payers, as in medical savings accounts, allows for the greatest opportunity for adequate treatment and confidentiality, based primarily on clinical need.
Residents and medical students should be encouraged to strive for excellence in clinical practice, maintain their integrity, and always place the needs of their patients first.
David T. Springer, M.D.
Wilmington, Del.