Sunday, March 26, 2017

Guest Poster Dr. Maher on Dealing with Changes in Psychiatry Through the Years (But Especially Now)

Obviously, psychiatry has changed over time. We've gone from a field where treatment was mostly psychotherapy-- I'll purposely omit insulin shock, leeches, and lobotomy-- to one of symptoms, prescriptions, and side effects, as though these things occur outside of the context of a person's life.  Ah, you've heard me rant before.  And like all of medicine, it's no longer just about treating patients, it's about checking the right boxes, coding what happened in the session by the minute, those damn CPT codes, and now about the technology and the hits your fees take if you won't e-prescribe, file PQRS (?huh) data, and practice the way the insurers want, if you choose to accept insurance or work for an agency that does.  With all that in mind, I saw this lovely and angsty post on Facebook, and asked the author to join Shrink Rap as a guest poster.  I was so pleased when Dr. Maher said yes.  Her guest post is below.

 I'll be 65 next month, I will have been in private practice for nearly 40 years, and I'm trying to decide where to go from here. If you have time, would you help me think through this difficult decision?
I trained in a time and a place when psychiatric treatment, other than for the severe mental illnesses, was about psychoanalysis. Even if you didn't go on for analytic training (which I did, right after residency, at one of the most classical institutes in NYC), your primary goal was to search for and speak to the complex humanity of the other. My 4th year psychopharm course was optional.

Yes, the classical model was flawed in significant ways, but over time I took what I needed from it, I owned it and I loved it.
Then prozac arrived on the scene and I woke up in a different profession. No longer was it about meaning and humanity and insight into who you are, how you got to be that way, and the unconscious forces that led you to get in your own way. No longer was transference the mechanism of action. My field became about symptom constellations, drugs and/or skills to fix what was wrong with you.

This perspective always felt wrong to me, but over time I came to integrate the parts that felt right with the work I was trained to do, and it worked pretty well. I have a very good practice, partially private pay and partially insurance based. Aside from Medicare (helpful when some of your patients have been with you for 30 years), the other insurance I accept is the one that the NYC Dept of Education uses. Many of my patients are teachers, so their psychopathology falls within a range that I'm comfortable treating.

Once long ago, that insurance company called and asked me to take a patient off their hands. She was a paranoid, depressed, obsessional, suicidal, entitled, angry and litigious woman who fired every psychiatrist she saw, called the plan daily and threatened to sue everyone she spoke to. I told them I would only take her if I could see her 4 days/week indefinitely, no questions asked. They said yes, and she never bothered them again.

They left me alone after that. I've seen some people weekly for years without being bothered.

But times are changing, yet again. No one would remember me from that time. No one would bend the rules to allow a shrink with dynamic understanding to engage a patient like that. The billing, coding and documentation requirements, and the medical complexities, are becoming more than I feel comfortable with. I'm finding it increasingly hard to integrate the complex, struggling human being that I see with the symptom and treatment picture that I'm required to see.

I've moved into other arenas, including a not-for-profit organization, documentary filmmaking, and the development of an emotional literacy curriculum for young people. But there's no money involved in any of them. They cost money.

I love my work and I love my patients and I think they benefit from working with me. I know what I know and I know when to refer to to ask for help. When I do psychodynamic "talk therapy" (I hate when they call it that!!), I'm doing something very complex, something I'm very well trained for. But there's no code for that and very little respect for it, and I live in fear of being audited.
If you've read this far, thanks so much. I'd be grateful to hear your reactions.


Unknown said...

As an incoming intern going into psychiatry, it was very interesting to read your blog post. I'm also curious where as a new psychiatrist where my career would go. I think it's nice to have the flexibility to be where you are and to not have another 4 years of training (at least) to go. It'd be fun to discuss with you more.

Joel Hassman, MD said...

At the risk of being received as a bit harsh, I have found that many of my colleagues who have been practicing for more than 40 years to be one or both of the following perspectives: too insulated from the realities of psychiatrists who have started as clinicians since 1985, or, out of touch with the realities that mental health care really demands as of the 21st Century.

I would hope Dr Maher is the exception to those above 2 perspectives, but, while I respect the role of psychodynamic therapy, as I have always preached that therapy is the mainstay of mental health (hence my moniker of "therapyfirst" I have used here on the Net for years), the bigger question is why can't psychiatrists be reimbursed for appropriate and applicable therapy interventions, and more so, why the APA is so silent on this matter.

And to relate that latter point of the APA silent complicity, why is it so many older colleagues who still are members seem to be so out of touch with the needs of their younger colleagues who are in the trenches, and almost literally supporting the older/retired ones who think they are entitled to a free ride?

No matter what happens with this Republican Congress and President per the future of Obamacare/Trumpcare/ or just FederalScrewUpCare, if physicians stay clueless or complicit that letting the government dictate health care decisions from all aspects, what are patients going to do WHEN doctors who care and advocate fiercely realize they are lame ducks? Who will be left to treat society? Non-physician providers, or even more chilling, physicians who don't care how they are controlled?

That is the mandate we who care should be focused on changing. Otherwise, does it really matter if a psychiatrist can still provide therapy, when people either can't afford it, or, there are not qualified clinicians to provide it for the next generation of care!

Yeah, I don't sugar coat the realities I have been witnessing these past 10 years, about 7 now as a temp doc, seeing lots of facets of mental health care being chiseled away...

Joel Hassman, MD
Board Certified for 20 years

Donna & Chris said...

Thank you. Lovely thoughts. I am a 60 year psychiatrist who mixes up meds and therapy in private practice. I worked for many years at a Kaiser-like org and it was fine, until it wasn't. I am not sure what I will do when my board certification runs out in 4 years. Probably leave the field.

Ann said...

Therapists who see the complexities of the human condition during the various seasons and stresses of life, and are able to wade through the brokenness of each client, are few and far between.

As a client who has seen several therapists throughout my life, I have learned to discern which ones "get it," and which ones are in too much of a hurry to be bothered with actually listening for nuances. The ones who listen for those nuances are the lifesavers, and those are the therapists who redeem the profession.

I want to thank Dinah and the countless practitioners like her who do get it, and continue to serve in this vital community service. Doctors like her make us one of the "go to" resources in the world today as a nation.

Steven Reidbord MD said...

My recommendation is cash-pay private practice (perhaps with the exception of your long-time Medicare folks). This is what I do, and in a world of trade-offs it's the best I've found. I'm able to practice as dynamically as I deem helpful, and to switch gears (or add meds) as a case demands. I answer to no one except my patients and my own sense of professionalism. I don't worry about e-prescribing, PQRS, or any of that. And I make a living doing it, unlike the other pursuits Dr. Maher mentions.

It's admittedly anachronistic, and it certainly can't help plenty of severely troubled people who lack the means to pay. For that reason, I also suggest either a sliding scale or pro-bono care for a subset of patients, and/or volunteering some time at a clinic — good for the soul, if not for income.

Why stress? Dr. Maher at 65 may want fewer clinical hours anyway, and after practicing nearly 40 years, deserves to streamline and shape the professional work she chooses to pursue. Those are my thoughts anyway.

Unknown said...

Joel, I agree with you 100%. Unfortunately, I am afraid the reason we are seeing this trend is because the current way of doing things is more financially remunerative for the APA and some of its top members, and acknowledging what you and the author are talking about would mean giving up on big profit margins for the organization and a large number of corrupt individual psychiatrists. Look at Biederman and the whole "Juvenile Bipolar" debacle. Looking back, it's clear Dr. B was on the take from day one, as he promised results to J&J before even doing a study on their drug. But what has happened to him? Is he in jail, did he have to face multimillion dollar lawsuits? Nope, he's still in practice at Mass General and doing talks for Big Pharma As long as folks can make millions selling out their patients, we can't really expect rational folks like you and the author to succeed at reforming the APA. It's gonna take a revolution from within the ranks, with both patients and professionals banding together and demanding change, and it is going to mean taking on the big money interests, and it's going to be UGLY. I'm not holding my breath on when it's going to happen.

Judy Kamau said...

Wow! 40 years! I marvel as I am only 7 years old in the field of psychiatry....
Well, you clearly love what you do, but you could scale back the hours some.... Write if you can about your beautiful journey, interesting stories (I avoid saying cases- takes the relaxation out of it)..... In my country, some of the few older psychiatrists participate in mentorship programs, charitable works, take up part time consultancies and therefore still continue to inspire....