The article below is being reprinted from this month's edition of The Maryland Psychiatrist. Dr. Hershfield shares his wisdom on outpatient treatment of patients, and of running a private practice. Please note the intended audience for this wisdom is younger psychiatrists, in particular, those just starting out. I'm not a younger psychiatrist just starting out, and in fact, I'd fail on a couple of these measure -- we all have to figure out for ourselves how best to practice in the context of our personality's and in the context of who are patients are and what they need. Overall, however, I thought Dr. Hershfield makes some excellent points and I wanted to share his wisdom. With thanks to Bruce Hershfield and to Dr. Nancy Wahls, editor of The Maryland Psychiatrist, for allowing this to be reprinted. The Shaw quote is for Jesse.
WHAT I’VE LEARNED
By Bruce Hershfield, MD
Now that I’m getting ready to turn 70, I thought I’d summarize what I’ve learned since I finished my residency at the University North Carolina, when I was 28. Of course, , I didn’t learn all this only by being a psychiatrist, since I would hope that most folks have also learned lots in the last 41 years., But our field has really changed, and so have I. This is what I tell the Residents, when I get a chance to meet them in a group:
1 Psychotherapy is important, particularly if the patient is on the right medication.
I won’t do “med checks”, since I would not want them if I was a patient. I figure if it’s simple enough to do in a few minutes, my family doctor can probably handle it or learn how to do it. If it’s complicated, it’s going to take me more than a few minutes. I knew when I was a Resident that psychotherapy was important. I realize now, if you have a severe psychiatric disorder like schizophrenia or bipolar disorder and you are not on the right medicines, you’re in a lot of trouble, no matter how skilled your therapist-- psychiatrist or non—psychiatrist-- is.
3 Try to get along with colleagues, even when they are being provocative. You may need to walk away, and you probably will need to apologize and also to forgive at times. Never fight with secretaries; learn from their observations. I should have read “How to Win Friends & Influence people” long before I turned 60.
4 Try to have as few bosses as possible. If everybody loves the boss, he or she probably isn’t effective. Never have more than one boss to whom you are reporting. All people – – not just patients – – have transferences, and they usually complicate relationships with bosses.
5 If you’re always agreeing with the general wisdom, particularly if money is involved, you will eventually be dead wrong on something. Atypical antipsychotics helping the negative symptoms of schizophrenia is a good example of conventional wisdom that turned out to be wrong. Beware of fads, don’t trust ads, don’t take professors or studies too seriously.
6 The more we know, the less magic is associated with us and the less respect we receive. It’s part of our attempt to climb out of the Middle Ages.
7 Psychotherapy is more about healing, which usually occurs in – between sessions, than about insight. Patients who are asking for insight are usually unwilling to change their behaviors. Patients who don’t do the homework probably will not learn new ways of handling problems.
8 You can’t tell who is going to be a good patient. Some people with little education and little command of the language can change and get well. People who have addiction problems are the hardest to predict. You probably should give them a chance if they ask. Even after seven years of chronic depression, for example, some patients recover.
9 People will pay for good medical care, particularly for their children. It is not an accident most psychiatrists are now practicing outside the managed-care system. Don’t allow managed-care companies to tell you how to practice. It doesn’t look good ethically and it doesn’t impress juries. Do what is right, even if it costs you in the short run. You still may get in trouble, for example with administrators, but someone may be impressed and maybe you’ll be rewarded. At least, be kind, if you can’t do any more than that.
10 Stay out of court, if possible. Don’t sue people, don’t dismiss the possibility that anyone can sue you, and be sympathetic when your patients get involved in proceedings. Lincoln was right when he advised a group of lawyers to “eschew litigation”.
11 Join societies and ask for advice from other members. If you’re willing to ask for a consultation, you are almost certainly not negligent. Patients are reluctant to get them. Arrange for consultations with someone whose advice you’ll almost automatically take. Don’t criticize colleagues to others, including to patients.
12 Don’t steal other people’s patients. Ask potential patients if they have ever seen a psychiatrist, when they first call. If it’s in the recent past, ask to have their psychiatrist refer them to you and say you’ll get back to them if that happens. Clarify beforehand if it’s for a one – time consultation or for ongoing treatment. If patients don’t show up for the first visit for any reason, or give you a hard time on the phone, you will eventually regret taking them into your practice.
13 Be available. Return calls. Have a call hour. Answer letters. Encourage patients to call you if they need you. Find someone to substitute for you whom you can trust when you’re away from the office for any significant time. Be very careful about prescribing for the patients of others when you cover for colleagues. Don’t charge for phone time. Most people won’t abuse it. If patients call too much, you probably need to see them more often. Don’t let patients go for more than 90 days without seeing them.
14 Document. Too much is better than too little. There’s more paperwork each year – – more work in general. Real earnings have been going down since the’ 70s. Follow up on lab tests. Write legibly. Your reputation may depend on the quality of your notes.
15 Be cheerful, even optimistic. It turns out it wasn’t Lincoln, but i someone else who said that he reckoned that people are as happy as they allow themselves to be. You can’t expect depressed patients to be optimistic, and someone has to be, at least to balance their pessimism. If you are a psychiatrist, chances are that most people, and virtually all of your patients, have it worse than you do. Don’t complain.
16 Keep learning. Read books, acquire new skills. I’ve heard that almost everything we know we’ve learned since 1950. Accept that what you know will probably turn out to be wrong or useless. They call that progress. Beware of people who tell you they know the answers. Your training will probably turn out to be a small fraction of your career.
17 Patients are probably right about side effects. Be suspicious about claims made by drug companies, including maximum recommended doses. Ask patients about drinking and about caffeine, not just about illegal drugs. Check with families. Be suspicious if patients forbid you to contact their families or the professionals who used to treat them.
`18 Get to know families. It’s crucial if something like a suicide occurs. Get a family history. I understand the average person carries the genes for 20 disorders, of which four are lethal.
19 Don’t treat members of the same family, or close friends, if you can help it. Don’t write prescriptions for your friends or coworkers. You can’t successfully treat everybody. Somebody else may be a better match. Sometimes, patients return after they drop out.
20 You work for the patient, not the other way around. Dress accordingly, use honorifics like Ms. or Mr., and ask what the patient wants. Set up a valid treatment contract, early on. Be wary of double agentry, like working for the patient and the hospital, or for the patient and the managed-care company.
21 Use “we” interpretations. This is not Europe; people expect to be treated as equals and they aren’t as tied to their traditions and their families as in other places. Sometimes a story or a fairytale can illustrate a point. Be careful about using your own life as the example. Patients can sometimes change if they are laughing, but be careful. If you offend someone, apologize. Patients don’t expect their psychiatrists to be perfect, but they do expect them to display good manners, like holding the door for them or offering them a tissue when they cry. Psychiatric disorders are common and chances are that someone you know, or even you, will get one.
22 If you’re going to work for yourself, you have to stay healthy. Take frequent vacations. Learn how many patients you can safely see in a row and what your personal clock tells you. If you are sleepy, excuse yourself and get some coffee. If you bring it into the session, offer the patient a cup.
23 Make sure you get paid. If you get cheated, learn from it. Don’t pursue it too hard; there are too many ways that disgruntled ex—patients can make you miserable. Be careful to document when patients pay you in cash.
24 When patients miss an appointment the first time, don’t charge. Make sure you call to find out what happened. If they can come later that day, let them. Patients tend to resent paying for missed appointments.
25 Be on time, or at least apologize if you’re not. Try to give extra time of people need it. They rarely abuse it and often appreciate it. Give plenty of warning before you raise your fees.
26 You will like some patients more than others. Some patients will like you more than others. You are neither as good or as bad as your admirers or detractors say you are.
27 Things go wrong. Admit it when you make a mistake. We are always on the verge of disorganizing, as is everything else in the universe according to the second theory of thermodynamics.
28 Diagnoses can be important. Hand the patient the DSM-V if you think that a personality disorder is present. That book has his limitations, but at least it uses a common language we’ve had since 1980. Watch out for indications of learning disorders. You may not want to make a diagnosis of a personality disorder, but it may be present anyhow and completely ignoring it may complicated or destroy the treatment.
29 The public system is in worse shape than the private, since government is not in the business of building reserves and sooner or later finds itself in a financial crisis. Also, there are too many bosses and too many political influences affecting patient care for it to be very good for very long.
I hope I haven’t finished learning. It is upsetting to realize how little we still know about what causes psychiatric problems. Our patients live better lives now than they did 41 years ago and I’m optimistic that we can help them live still better lives in the future. I used to think that I would retire when I turned 70, but I decided not to do that. There’s too much going on for me to quit now.
A nice "open letter" type post, but, let's be real, how many people in residency or out less than 5 years will be able to take his observations and recommendations to full consideration and acceptance? Perhaps what would be a nice effort from the people like Dr Hershfield is writing an open letter to residency directors, who seem to be complicit to what Dr H is warning NOT to do.
But, we who live in the real world know how such correspondence would be received by those who answer to insurers, Big Pharma, politics of academia, and cronies, er, colleagues who rub each others' elbows at APA functions.
Very nice post though, liked it and agree with it overall. Especially the part about not underestimating Axis 2 factors. I'm sure that surprises you to read...
I enjoyed this and almost 100% agree!
This was excellent. I wish I could find a Psychiatrist like Him...I had two, 0nce. Lost the first one when we moved and the second when he finished his Residency. :(
I just wanted to make a quick comment to say GREAT blog!….. I’ll be checking in on a regularly now….Keep up the good work
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Great recommendation to ask a new patient with a prior psychiatrist to have that Dr refer for care.
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