Psychiatric medicine has changed significantly in the last one hundred years. Many predict that the next century heralds even greater scientific advancements for the field and for care of the most seriously mentally ill patients. Our original mission as physicians was predicated on service to patients. As this century closes, current studies have noted changing demographics with large numbers of potential patient groups among the poor, our children, the elderly, and ethnic minorities, and mentally ill individuals are increasingly being housed in prisons and jails instead of hospitals. The ability of the mental health profession to address adequately the psychiatric needs of these patients will present significant challenges to the field, to the business community, to our legislative leaders, and to our rich country. There is no question that psychiatrists in cooperation with families, patients, and other mental health organizations will continue to have an important role in advocating for patients’ access to psychiatric care, patient rights in health care, and an improved service delivery system.

But there are storm clouds on the horizon that could threaten the viability of the relationship of trust that physicians have always shared with their patients. In May former Surgeon General Julius Richmond addressed the APA Assembly and encouraged us to remember our historical and ethical bonds with patients and to avoid getting sidetracked in our work with patients by the various reimbursement issues in medicine. Twenty or 30 years ago, most of us practicing psychiatry were not fully informed about the impact of a managed system of care on medicine. Today, I believe that all of us recognize the significant impact of these changes on our patients’ access to health care and on our ability to provide appropriate mental health services.

A recent AMA survey of internists reported that some physicians would lie to managed care plans in order to get medical services for their patients. Critiques of physicians as entrepreneurs in medicine, physicians and residents as union members, and the public promotion by one of America’s most popular surgeon generals of his popular Internet site may contribute to some reported skepticism of the physician’s dedication to the patient first. This fits into the theoretical models used by some health economists that hypothesize physicians as primarily motivated by their own interests, according to Uwe Reinhardt writing in the February 3 Journal of the American Medical Association. It must be our duty as physicians—whether psychiatric clinician-practitioner, administrator, researcher, resident, or entrepreneur—to be ever vigilant of the bond of trust with the patient.

Medicine’s future may bring even more twists than we can now conceive to the rapidly changing patterns of reimbursement in health care. Some of these yet to be recognized ideas may provide a nidus around which a more inclusive health care system will be designed.

Medicine cannot afford to allow such a system to be drawn primarily from theoretical models conceptualized exclusively by health economists since it does not value the sanctity of the patient-doctor trust relationship. It will be important for psychiatric physicians to continue to research and to experiment with new treatment methods, pharmaceuticals, and systems of care, but the primary motivating factor for us must remain that the patients’ benefits and needs are foremost. 

Dr. Norris is a child psychiatrist and medical director of Parents’ and Children’s Services and a private practitioner in Boston. She is the Immediate past speaker of the APA Assembly and serves as a member of the Finance and Budget Committee and the Editorial Advisory Board of Psychiatric News.