Friday, October 05, 2012

I Chose the Wrong Profession

Oh, actually, I love my work.  I love seeing patients for therapy and I've seen over and over how helpful medications can be, so I'm glad I can prescribe them, and I love that most people feel better (or they quietly move on and I don't know).  

So far, I chose the right profession.  Hoping that holds for a while.

I entered college with plans to become a psychologist.  I didn't really get the differences between a research psychologist and a clinical psychologist.  My university also offered a major called The Biological Basis of Behavior, and there was a strong graduate program in experimental psychology but not clinical psychology.  I thought I wanted to be a researcher, and I majored in both Psychology and "BBB" (as it was called).  At the end of my second year, I had the thought that I would like to do research but I'd like to see patients as well.  There was no one to tell me that Clinical Psychologists can do both, and so I figured that going to medical school and becoming a psychiatrist would give me more options down the road.  So I went to medical school -- in New York City, where psychiatrists back then were often psychoanalysts and I'd never even heard the terms "med management" or "split treatment" -- and I became a doctor, then moved to Maryland and became a psychiatrist.  I liked that there were so many options, and I realized I really liked seeing patients and that research was more about writing grants (and praying you got them) and concerns with data in a way that I'm not primed for.  

Back then, I had no idea that social workers did psychotherapy.  As a medical student, and even as a psychiatry resident, I saw social workers do family therapy on the inpatient unit and arrange for discharge planning, help patients obtain benefits, and arrange for aftercare programs.  I was well into residency training before I realized that psychotherapy was mostly done by social workers.  

I had no idea that there would ever be any expectation that I would see 3-4 patients an hour and confine my work to asking about symptoms and side effects, much less the time consumption that filling out paperwork (soon to be computer work) would become in clinic settings.  

I brought this up because we've been talking about capitated care versus fee-for-service care on an earlier post.  I think the capitated care folks are winning so far, they seem to like their system.  But in 2012, in capitated care systems, psychiatrists do management, they don't do psychotherapy.  Where would that leave me?  Am I worried?  No, there seems to be a demand for what I do, and neither presidential candidate has come knocking at my door for suggestions, so I'm just hanging out to wait and see.  I am feeling a bit obsolete and like somehow, I ended up on the wrong train. What do you think?


withallmyheart said...

I was a very troubled person, growing up in a very troubled household in NYC. In 1967, I was first hospitalized at Payne Whitney, and for 10 months, I sobbed and wept - my sorrow and despair seemingly knowing no end.
~~I am still in treatment with a Dinosaur, and therapy, and medicine, and sometimes hospitalization, continue to save my life.
My progress through these decades has been slow, dinosaur-like, you might say.
I defy anyone - from the insurance companies, especially, to listen. Listen to those of us who know what it is to learn to trust, learn to live,learn to choose life, through psychotherapy (with a psychiatrist). I am blessed beyond blessed, and tous a la fois, I know how fragile I am still am. Thank G-d for my Shrink......

Anonymous said...

I'm sure that being a psychiatrist adds to one's value as a psychotherapist, but how much is that added value worth? If someone is paying out of pocket they can pay what they want. If the case is complex, again, that added expertise might also be worth paying more. But if it is paid for by insurance, which whether capitation or fee-for-service, why should the system pay a psychiatrist more than a psychotherapist for problems that could be treated just as well by a psychologist, psychotherapist, or therapy trained social worker?

Anonymous said...

btw, I'm not devaluing psychiatrists. There are physical conditions which mimic mental illness, there are complex mental illnesses and people with both physical and mental health complications (e.g., someone with epilepsy and OCD) where the pharmacology is delicate. My concern is that mental healthcare should be affordable and paying for a Rolls Royce when a Toyota will get you there is ridiculous. If a psychiatrist is doing psychotherapy, that's how s/he should be paid.

It makes me nuts when price determines value. Recently a friend of mine decided to have therapy. Despite my being a therapist, she turned down my reasonably priced recommendation of a therapist who I felt would be an excellent match in terms of personality and approach for her. She chose instead to go to someone who charges 3x as much because she'd heard he was good for business people like her (and she didn't even like him).

Anonymous said...

I know this feeling well. I became a therapist so I could help people meet their own goals. I anticipated self-motivated clients who wanted to recover to be my predominant clientele. Instead, in the managed care system, I am more often an avenue toward SSDI, a letter to truancy court, a way to get extra services through the school system- or another person "responsible" to "fix" children who are ashamed to be in my office at all because of the double messages their families send them about people like me. I rarely get to do "therapy" anymore, with its client-centered focus and empathetic, warm environment, working at a client's pace. I do a lot of glorified case management with a smattering of the "real" work with those precious few who are truly interested in coming to get help, and not dragged to see me by a parent, an agency, or a district. I often feel used by families who are not interested in a therapeutic relationship but rather what my credentials can do for them, and I often feel like I am being expected to participate in the shaming and traumatization process of adolescents and children.
Grad school definitely didn't prepare me for the bureaucratic mess that is the managed care system, or the variety of different ways people have found to use the system for purposes other than self growth and recovery.

Anonymous said...

I do spend a lot of time not doing therapy, but I try to make what I'm doing, whether writing a report so a child can get accommodations, liaising with social services, or meeting with teachers, a therapeutic activity. Sometimes my job is to get the wider system to see their role in helping my client and seeing them as a individual in context rather than just a label.

While I appreciate the frustration and feeling like we are banging our heads against a wall some times, the comment about "self-motivated people who want to recover" really hits one of my buttons. Change is difficult, but not because people aren't motivated. We might be miserable as things are and it might seem clear to everyone that something needs to change, that we need to change, but that involves an awfully big risk, because there is no guarantee that change will have a positive outcome. Generally we are surviving even if we are miserable, and it is a misery we know in the face of uncertainty. We have to be more afraid of not changing than we do of change before we can take that leap. I think far too many practitioners spend too much time on motivating change than in exploring the obstacles and risks and determining what is a reasonable hope. People don't have to engage with us, but it is our responsibility to create the best possible opportunity for engagement.

Dinah said...

Anon who says "why should the system pay a psychiatrist more than a psychotherapist?"

Answer here;

So should a LPC (licensed professional counselor) be reimbursed the same as a Social Worker, and the same as a psychologist with a Masters' Degree and the same as a psychologist with a doctorate?

I often see people who have failed other treatments.

Anonymous said...

"So should a LPC (licensed professional counselor) be reimbursed the same as a Social Worker, and the same as a psychologist with a Masters' Degree and the same as a psychologist with a doctorate?"

That isn't really my argument. When it comes to insurance (whether commercial or nationalised), people should be sent to practitioners who have the right qualifications for their problem. So, for a patient with treatment resistant OCD, definitely the system should pay up for your level or expertise. But for someone with mild anxiety, no, I don't think they should be reimbursed for psychiatrist-level fees when a licensed-counsellor would do. I think it is an ethical issue.

I'm not sure the level of degree always is the best indicator of therapeutic expertise. I have friends with Masters Degrees who know as much as I do (and more within their specialist areas) with my Doctorate, the only difference between our training that I can tell was the length of our dissertations!

Anonymous said...

What I love about working in a multi-disciplinary team is just that - we work as a team. We all do assessments, though if the problem seems specific such as an eating disorder we would set up the first appointment with someone with that expertise, then the assessment is discussed by the team before an initial care plan is made, whether if that is for a specialist or generic service. So every patient's case is reviewed by a psychiatrist and psychologist and social worker and a psychotherapist and that means no one has to be everything for everyone and we can match patients with the write person and approach. I see it as a definite advantage for managed care providing the best to patients cost efficiently.

Dinah said...

So how do you pre-determine exactly who needs what level of care? Do we insert a separate layer of bureaucracy to have a professional do a psychiatric evaluation and then determine what level of professional is most appropriate?? I often suggest weekly psychotherapy at the time of the evaluation, a 2 hour session, and when the patient starts medicine, and feels much better 3-4 weeks later, suddenly they don't need weekly sessions. It would take a working crystal ball to know who needs who will respond to meds alone, who needs therapy at the precisely right amount. For many people, my one-stop shopping is much cheaper then seeing a psychotherapist who would have them coming for years, and many of my patients have failed med management treatment ("I go every month for 15 minutes and every month he changes my meds").
The primary care doc is often the referring site, and they don't know what psychiatric care the patient needs, that's why they are sending them to me.

Anonymous said...

right approach of course, not write approach! I'm sure there are other grammatical and spelling errors - apparently 4 degrees isn't a guarantee of spelling expertise either!

Anonymous said...

I believe that primary care givers don't have the expertise to prescribe psych drugs. I have been on some type of antidepressant for 20 years and the only time I got really messed up was when I let my Intenist switch me from Zoloft to Welbutrin. I went nuts! After that I will only use a psychiatrist who understands the meds. I also lucked out because my psychiatrists also does therapy and does it well. His medical experience and ability to do therapy is worth more money to me, because now I have "one stop shopping"!

Anonymous said...

Again, I disagree. As I posted in your last post - I have a state sponsored HMO - union employee. I pay out of pocket for my psychiatrist-who-does-therapy-twice-a-week, in NYC, where psychiatrists are practically expected to charge obscene fees. It reimburses me approximately 90% within 3 weeks of submitting (monthly bills). The last three HMOs I have had over the last ten years were quite similar.

There are options. Maybe you just don't know about them.

Anonymous said...

I agree with Anon above. I also took a lower paying job for one with good benefits. I am happy with the coverage I have. I am also very grateful for the good care I received when I did not have insurance.

Anonymous said...

To the anonymous who spoke so wisely and compassionately about the difficulty of change--thank you!!!!!

Anonymous said...

FYI, the best therapist I ever saw was an extern-level clinical psychologist. Some of the most dangerous, unethical and harmful clinicians I ever saw had 25+ years of psychiatric experience including top notch NYC hospitals. Too bad it's not a meritocracy - practitioners could get paid for what they provide. There's an idea! Responsibility and transparency for psychiatrists...what?!

Jane said...

The problem with capitated care is that I think it causes docs to go into denial. I was watching Dr. Drew last night, and there was a woman with acromegaly on it. She is 7 feet tall and 440 pounds, or something like that. At 19, before she got the condition, she was so pretty and petite that she was offered a modeling contract. It took 10 years to diagnose her. Someone called into the show and asked how that was possible. And Dr. Drew goes, "I don't know. I don't have an answer to that." But he opined that Docs don't really get to string things together anymore like they used to. The woman with acromegaly agreed. Whenever she saw a doctor about her issues, which manifested mostly with severe headaches, tingling, etc, they just thought she was having headaches that needed meds. They didn't really string it together. She finally went to see her pediatrician that she saw as a kid, and it was the pediatrician who figured it out...The pediatrician knew her history and strung it all together.

In my own family, my mother went far longer than she should have without a breast cancer diagnosis because she was under the age of 40, and I guess that the doc didn't think women as young as her could get it. 40 was also the age for routine mammograms. I think he just knew the constraints on the system and didn't want to order a mammogram because he had it ingrained in his head that 40 was the age for breast cancer. Something similar also happened to a 17 year old girl in my town. She went to a few different doctors about a lump on her breast and was told she was too young for breast cancer. They didn't run any tests. When she went to join the Peace Corps after graduating high school, they conducted a physical exam on her...they discovered that she had stage 4 breast cancer.

There are real issues with capitated care. There probably are really complex psych cases that would greatly benefit from a psychiatrist/psychotherapist. But capitated care is meant to be very restrictive, and it is not designed for outliers. It is not designed for an atypical psych patient, a 17 year old with breast cancer, a 19 year old with acromegaly, etc. It is designed to be as superficial and cheap as possible.

I think fee for service will always be available in America. If everything were part of a capitated managed care system...there might be no hope at all for some people.

Anonymous said...

In the UK and elsewhere the capa model has been found to be an effective, collaborative way of offering mental health treatment ( It was pioneered in child and adolescent services, but is used by some adult services with good results. Of course any model is only as good as its implementation.

I can understand why a "one-stop-shop" would seem attractive, certainly if therapist and psychiatrist don't work together. But a system that operates on the basis of joined up work offers better patient choice as well as the advantages that come from the debate and pooling of knowledge from different disciplines. For example, why would medication be the default start point when, for most disorders I can think of, combined treatment with a psychosocial intervention (which may or may not be therapy) gives better results? Why medication at all for mild to moderate anxiety or depression that could be reasonably treated with therapy alone?

Anonymous said...

Just to be clear, I'm not saying the US should copy the UK (the protests here today are a pretty good indication that we haven't got the system sorted). Also, I've no doubt there are some people for whom medication only is the right option and that therapy with a psychiatrist can be valuable!

While it can be annoying in the moment when colleagues debate my treatment plan, I do realise that their playing the devil's advocate helps patient care! For me, our multidisciplinary team approach offers the least problematic set of dilemmas, but friends of mine who work privately or in different types of teams it sounds like a nightmare!

Anonymous said...

same experience from pt perspective

Anonymous said...

"I think fee for service will always be available in America. If everything were part of a capitated managed care system...there might be no hope at all for some people."

This avoids some big issues. I believe that any system of healthcare is going to fail many individuals. Where is the hope for people who have no way to pay for medical care (preventative or acute) and/or have to make intentional choices to risk their health/longevity in order to meet more essential needs of theirs and their families? It comes as no surprise to me that rare, rarely diagnosed conditions rarely get diagnosed and treated well, regardless of the kind of healthcare system we have. However, I find it more shameful we use that as an excuse to spend more money on highly specialized care that so few can afford that leaves large amounts of people unable to access care for easier to diagnose and treat conditions. Especially when people without health insurance or previous care end up in a hospital (regardless of their intent to go), the public is still on the dime for the super high cost of care for treatment that probably already it too ineffective too late. I'd rather be able to have be part of a system that makes it more likely that I can quick, effective care for health issues that are more likely, that uses some bayesian reasoning to recognize that these conditions are the most likely to be occurring and need to be ruled out before looking for alternative explanations, and recognize that even if I do have a condition that is rare and difficult to diagnose/treat, I will be able to continue engaging with a healthcare system before my money runs out and I couldn't seek care at all.

Government capitated systems offer better, more accessible ways for more people to receive quality care. If you compare health across populations of countries with more capitated care systems vs. the US, you see populations with better health, better care, and the healthcare system is cheaper. I think there are some important areas where they can be strengthened in regard to practioner evaluation, linking pay to even more meaningful outcomes (though the systems in place are already a step ahead of the US's insurance company determined fee-for-service/output model), and investing in more in wellness so people are less likely to need medical services in the first place, the "health" of these countries the cost of healthcare to that health ratio is far better than it is here in the US. This allows people to spend more money and time doing other things that worrying about their health.

Anonymous said...

Dinah -Your quote" ...Psychotherapy was MOSTLY DONE BY SOCIAL WORKERS". would never make it past my Psychologist, who is a specialist in Cognitive Behavior Therapy at a world reknown Research and Treatment Facility in New York.
If I made that comment, his response would be "do you have the evidence to support that?!"
Do you, Dinah? If you do, my apologies.None of the many people I know who are in therapy, is being treated by a social worker, though we may not be representative of the general population,obviously.In my all too extensive experience as a patient in "psychotherapy" my experience is that Clinical Psychologists are far better trained as psychotherapists. After all, the medical school education received by psychiatrists, is identical to that received by M.D.s who go into other specialties.Psychiatrists need not have majored in psychology. Psychiatrists receive a Medical School education which is identical to that received by physicians who go into other areas of practice.Most Psychiatrists' training in therapy seems to be limited to their psychiatry residency. Psychologist, on the whole.spend far more years studying psychology, than do psychiatrists. Admission to doctoral programs in Psychology is actually far more competitive than admission to medical school. My college adviser actually suggested that I apply to medical school if I wanted to be a therapist, as at the time (the early 1980s) 1 in 3 who applied to medical school was being admitted, versus 1 in 17 who applied to a doctoral program in Psychology. I have not come across any psychiatrists who have received extensive training in conducting C.B.T. or D.B.T. which are the only "therapies" which "evidence based." Psychiatrists can make far more money than can psychologists or social workers, for billing for shorter increments of time at a higher rate of compensation for medication management, should they choose, than can psychologists or social workers who can bill only for psychotherapy. I do empathize in terms of the ridiculously low compensation rates being accorded to psychiatrists, primary care physicians, etc as compared to certain other specialists.The system is certainly "broken" and I don't foresee anyone coming along and fixing it in the near future ,if ever.

Sick of being anonymous said...

To the above anon...

Well, there are more social workers than there are psychologists and psychiatrists. (I don't know where counselors and psychiatric nurses fit into this). Given the great number of social workers, that they can be reimbursed for talk therapies by insurance companies (they have an incentive to do talk therapy and insurance companies have an incentive to pay them [less than psychiatrists]), and that psychiatrists get paid quite a bit more the more exclusively they focus on medication management, I think it is safe to assume that social workers are doing the bulk of psychotherapy.

Another side note. Evidence-based therapies are not evidence based just as themselves, but in their application to particular populations with particular diagnoses/characteristics. So saying, for example, "DBT is evidence based," is not accurate. Saying there is an evidence base for DBT in treating particularly suicidalality in women with Borderline Personality Disorder is accurate. or There is an evidence base supporting the use of CBT for reducing depressive symptoms in people with Major Depressive Disorder. There isn't an evidence, for example, for DBT in treating negative psychotic symptoms of schizophrenia.

I am really behind the evidence-supported treatment movement in mental health, but part of that is being clear and honest in regards to the extent and quality of the evidence.

Anonymous said...

"I often see people who have failed other treatments."

Part of being a good practitioner is recognising when we're not being useful and helping clients find someone who might be more effective for them, but barring actual incompetence by previous practitioners, aren't we sometimes just the right person at the right time?


p.s. Has there been a discussion here about what "counts" as evidence based practice (and the value of practice based evidence). Now there's a whole other debate!

EastCoaster said...

I mean, I think that there are different types of managed care, and that there are a lot of promising ways to do it.

My agency just got a grant to target something called a health buddy to 25 of our sickest patients with both psychiatric and medical problems. Part of what we are doing is teaching better self-management techniques, but there will be a nurse practitioner who can monitor the data every day, do house visits and hopefully intervene before these patients need to get to the ER. The particular group we're working with has expertise with elderly people who have both medicare and medicaid and are fairly sick. They're empowered to do things that have not traditionally been considered medical care in the hope that they can keep people out of nursing homes which is incredibly costly. The capitation allows a lot of flexibility. Somebody with a flea or tick bites shows up in the ED several times needing creams, but fumigating their housing solves the underlying cause. That saves money *and* it's better care.

Behavioral health is tricky, and I think that finding a way to integrate independent mental health providers into ACOs is something that I think about a lot.

Jane said...

Anon: What I mean is that I live in America and have always been part of an HMO, and it's really good care...until something goes really wrong. Then it isn't that while I do think capitated care has a place in America, I think there will always be a place for fee for service.

Capitated care is good for someone who has easily treated depression, etc. But there should always be fee for service and a way to get an opinion and treatment outside of the system