Why cognitive doctors need to be paid more

Everybody has a theory of what’s wrong with American health care and why costs are high.

I have my own theory – talk is cheap. By this, I mean Americans and third party payers are unwilling to pay more for what mere talk is worth.

They do not want to pay more for a visit to the family doctor, other primary care physicians, or a psychiatrist. They pay primary care doctors only 55% of what average specialist makes, and only 30% of what an orthopedic surgeon takes home. A psychiatrist is the lowest paid specialist.

A front page headline in a recent New York Times nails the problem: Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy.

A psychiatrist can make $150 out of three 15 minute sessions with a patient followed by prescription, but only $90 for a 45 minute talk consultation. A prescription pad has replaced the couch.

A visit to the shrink has become a brief chat, a prescription, and you’re out of there. Many of the nation’s 48,000 psychiatrists no longer provide talk therapy. Instead, it’s a 15 minute session with a prescription adjustment.

The situation is similar for primary care physicians. Only the visit may be even shorter, 10 minutes or less. As Steven Sharfstein, a psychiatrist who serves as president and CEO of the Sheppard Pratt Health System, Maryland’s largest behavioral health system, says of a psychiatrist’s practice, “It’s a practice very reminiscent of primary care. They check up on people, pull out the prescription pad; they order tests.”

Practice becomes all about volume. Treatment becomes a production line.

So, fewer doctors enter primary care and psychiatry. Doctors in these fields switch to other specialties, retire early, or become health care executives. More health policy types bewail the primary care shortage. Increasing numbers of onlookers say we have to re-jigger the payment system by paying “cognitive doctors” more like “proceduralists.” Critics seek to restructure the RUC (Reimbursement Update Committee), in which a specialist-dominated committee appointed by the AMA and slavishly submitted to by Medicare, sets doctors’ fees.

But there’s a huge cultural problem nobody talks about. We’re an action-oriented people. We like strong silent men of action. Talk is cheap, and we’re unwilling to pay more for it.

Americans want action – a prescription, a laboratory test, a CT or MRI, a procedure.


Something concrete. Something we can touch, feel, take, ingest, inject, point to, biopsy, grasp, identify, undergo.

Something we can share with friends and family, even if it’s a surgical scar, a pacemaker, a vascular port, a hip or knee prosthesis.

Americans get all the talk we want – from talking heads on radio and TV, from channel news shows, from the Internet, and from bloggers like me.

Other than rewarding talk and recognizing and rewarding cognitive physicians for time spent with them , we should, of course, pursue the big things. ‘

Joe Flower, a health system change guru, suggested five of these things in a recent piece in The Health Care Blog.

  1. New business models – retail care, urgicare centers, free (but profitable) fee-for-service clinics, specialty clinics, bundled care organizations, onsite clinics
  2. Integrated systems
  3. Organizations featuring shared financial risks
  4. Building a stronger primary care base
  5. Applying management tools – leaner care models, benchmarking , continuous quality improvement, and checklists

I am all for these things. If Joe will forgive me, let these Flowers bloom. But in the meantime, let us pay our thinkers and talkers, our cognitive doctors, more.

Richard Reece is the author of Obama, Doctors, and Health Reform and blogs at medinnovationblog.

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  • Sara Billings

    I agree, talk is cheap. The healthcare crisis that no one wants to talk about is end of life care. It is where ALL the money is. We continue to do procedures on patients in a futile attempt to save them for a quality of life that no on wants. I am speaking of the demented NH patient. If docs were paid more for end of life discussions and Medicare did not incentivise procedures we would not be in this mess. As a nurse for more than 31 years, I have seen the decline in medical mgt and seen greed run wild. I have seen Hospice patients receive new joints, pacers and feeding tubes. why? Because no one will take the time to have the difficult conversation. We do need to pay docs more for this, but we could spend a little time on a class in ethics as well.

    • Family Medicine Doctor

      Dear Sara Billings

      I agree. But its worse than you think. For years now, I have done hospice for a living. . I have seen patients have everything done you wrote: pace makers placed in terminally ill patients the week before they are sent to hospice, patients with end stage dementia- and i mean END STAGE ( mute, eyes shut 24/7, concentration camp survivor cachectic, bedbound, fetal position with contractures)-with a G-TUBE placed just as they are placed in hospice. Why would we do this to a patient who is existing like this and no longer living? Cause what you said above: no one wants to have that difficult conversation with the family. I have seen cholesterol meds being given to hospice patients. Yeah, insane. And costly.

      But you know what? Even if you are doing your best, trying to have these difficult conversations with families, trying to be a good doctor, the world still doesnt want to hear it. I cant tell you how many times i have had this conversation- “please stop the Lipitor for your mom with terminal breast CA” ( terminal meaning she is bedbound and soon to die) cause its not helping, only for the family to get mad at me and fire me, saying ” do you just want my mom to die?!?”. And it doesnt end there. Many hospice companies are for-profit and they want their patients happy so if the family gets mad, they get mad at me. They allow G-tubes to continue. Why not? It prolongs the patients life and the hospice company gets paid only while the patient is (sorta) living. Inappropriate.

      Yeah, i agree with you, Sara. But even if a doctor does the right thing, it sometimes bites him back. So there is no money in it and these conversations that you want us to have (although i agree with you) get us in trouble.

      The other place money is going is the treatment of obesity. Diabetes, HTN, and all the complications of those diseases (DM and Cardiovascular disease are the two leading causes of death). Because society is so obese- 30% of Americans are obese, the health care cost will remain very high. But there is no money for the primary care doc like me to talk and counsel my patients to better choices and lifestyles. It all goes to my specialist collegues to do the pace maker, hip replacements, and G-tubes.

      And nothing is going to change. Even with Obamacare.

      • alpna

        I agree doctor. Patient has a mindset. they are ready to pay for procedure even an injection or dressing but does not value a suggestion even worth millions. But somewhere blame comes to the doctors. This condition is created by us in a way and onus falls with us. Why at all should we entertain medical advices on telephone or on chats or during a social gathering. The medical advice should be restricted to doctors chamber very professionally and with a strict fees structure as per time time taken by the client. Since we have made advice available so easily we are misused and people do not want to pay. This does not happen in other professions like lawyers or tax advocates or counseling sessions

      • http://getaheadwithdrg.wordpress.com psychmd

        I agree with you wholeheartedly. i am in the same position as a CL psychiatrist when I get consults for decision-making capacity for terminally delirious patients, who are still full code, getting MRIs, medications for untreatable issues, and are going to die within months. But no one wants to say it. And you feel like the bad guy, but who’s advocating for the poor dying patient? It’s a hard job!

  • Sandra

    If people want to explore the reasons, the irrational beliefs and anxieties, and or the thinking that leads them to depression, etc, cognitive therapy would be desired. Drugs can mask the emotional but without onsight about source of emotional problems, it is not a complete success, and old thoughts may reemerge as soon meds are discontinued, and no new behavior has been learned

  • http://www.pulsus.wordpress.com Linda Pourmassina, MD

    I would like to add that, particularly as an internist, I think and “talk,” even more outside of a visit. For example, when the patients’ labs come in, or when I am consulting over the phone about a patient, or when I am reviewing old records, x-rays etc. Or when I am getting phone messages about a patient. Or when I am filling our forms for home health or insurance.

    Thus the care of one patient can extend greatly beyond the face-to-face time. There is even more cognitive activity – which would appear to be inactivity to some, per this article – than alluded to above.

    I once kept a very close record of how much time I was spending with patients and how much time I was spending in “indirect care.” And I am not talking about administrative work. This was managing prescriptions, phone calls, messages, forms, etc – all related to patient care. This post just gave me an idea for my next post. And I will publish exactly how much time I would spend in a day on indirect care….

  • BZMD

    I went into medical school wanting to be a psychiatrist. I wanted to be a man like Freud, Adler …. I imagined how I can help patients with psychotherapy and psychopharmacy. And then I got a rude awakening in medical school. Talk does not pay , medicine and labs do. Besides a casual “how are things going?” , The psychiatrists did nothing but act like pharmacy managers. Just like that I was completely turned off. I am now training to be a gynecological oncologists and love nothing more than to be in the operating room where I feel like I am actually doing some good for patients.

  • http://minochahealth.typepad.com/ Anil Minocha

    I wholeheartedly agree with the premise of the post and many of the comments therein. Thinking and talking to patients takes atleast same amount of time. I practice in Shreveport, La. Here like in many other places across the country, the interventionists irrespective of the speciality are likely to living in big mansions and driving fancy cars as compared to the physicians whose practice is primarily cognition bases without procedural interventions.

  • solo fp

    I would love to talk to patients for 60 minutes each. Try figuring out how much a level 5 is with the extended visit codes? It is much easier to document 4 level 3 visits an hours and talk for less than 15 min each to 4 patients than it is to get a high level visit covered or appropriately paid by most insurance companies. The rest of the time spent fielding lab results, prior auths, and other calls is all part of the primary care free services. Insurance companies and patients are not willing to pay for talking. Docs, unlike accountants and lawyers, are not viewed as professionals who are valued financially for their verbal input.

  • Mb

    As a patient battling depression and complex PTSD, I have paid, out of pocket, $10-15,000 per year on pyschopharm and therapy from a psychiatrist. By comparison, I recently had invasive back surgery for which I paid only $600, because skilled and availalable physicians were within network (compared to the psychiatrists in network with 6 month wait lists and no talk therapy). While there may now be parity laws, there still remains a disabling stigma against mental illness–both for patients to seek treatment and physicians to pursue the specialty. There are also barriers that must be overcome in terms of compensation, structure of work, and recognition of the value of work for psychiatrists. We recognize as a society that depression costs $millions, yet plastic surgeons make more money? Time to evaluate our values as a society.

  • LTW

    Re, psychiatry: Cognitive therapy is alive and well. It is just that we have figured out that we don’t need MD’s, with seven years of education and then post-graduate training, to do it and get paid at MD rates. The only part of the NYT article (and BZMD’s comment above) that resonates with me is the human cost to Psychiatrists as they are replaced in the talk-therapy sphere by MSW’s and others with Masters degrees who will do their jobs more cheaply and nearly as effectively.

  • D Hawk

    Specialty doctors…by my experience,most are arrogant, they hear, but do not listen to the patient and most of all, they do not take the time to know their patients. Follow up visits are a joke…the doctors want to know why the patient is back. Specialty doctors want to make money, not help people. Payment at time of service is more important, which leaves the underclass population without decent health care. Its time for the “special” doctors to accept public aid patients.

    • Fam Med Doc


      As a primary care doc who is struggling with low reimbursement & even wondering why primary care was the chosen field after medical school, I gotta disagree with you. Most of the specialists I know genuinely care about their patients & want to help. They work long hours & help make lives better.

      In regard to your comment “accepting payment at time of service”: no one expects someone else to work for free.

      Except you I guess. Why is that?

      • Oda

        Thank you.

  • Michael (chiropractic medicine student)

    This problem is due to the messed up nature of payment reimbursement plans by the insurance companies. Dr’s of chiropractic medicine have to go through this all the time. Unfortunately , until primary care physicians and chiropractic physicians have better cultural authority, no one is willing to pay anything (And that goes for the insurance companies too). Most people see a doctor when they have a current problem, it never occurs to anyone to see a doctor to prevent a problem e.g regular check ups. It is unfortunate that insurance companies make some doctors neglect the Hippocratic oath unintentionally. Doctors should do no harm. But if a doctor is not spending enough time with a patient due to payment reimbursements, prescribing a certain type of medication could do more harm to the patient if the doctor does not know exactly what is wrong with the patient due to the brief encounter with the patient. This is truly sad

  • Leslie, Clinical Counselor

    Based upon the above conversations, I would say the first problem is that MDs are too focused on going into medicine for the money and are too worried about what their MD colleagues make in comparison to their own.

    BTW, research shows that in mental health, prescriptions with talk therapy is more effective than prescriptions alone. For decades, the complaint by patients is that their regular doctors don’t spend enough time with them in appointments. MDs in general, have not spent adequate time with patients to really discuss the full spectrum of preventative and long range healthcare needs. I believe that if doctors spent the time to really listen and focus on the patient in the moment, even for a short time, we might actually curb some of our cultural need for immediate gratification, ie., meds.

    I do agree that culturally, we have a blind spot to the reality of death and dying. But if doctors don’t address their own professional struggle with the complexity of end of life or quality of life care issues, than they are simply modeling to patients and patient families that the only solution is to keep someone alive at all costs. It goes back to, spending time with individuals, as mental health or primary care providers. People can’t accept death and dying, partly, because they haven’t been given the time and space to process and deal with all of the other losses experienced over time in one’s life. In the hurried society we live in, we are attending less and less to this human need, and it has long term physical, emotional, mental, developmental and educational repercussions for individuals and society. Giving professional “care” helps people to practice dealing with that ultimate, irreversible loss, of someone primary in their life. But throughout our care giving professions (teaching, social service, nursing, medical and mental health, etc.) we are under such demands from outside influences in the desperate need to catch up to the demands of our hurried and wounded society, all the while keeping costs to a minimum, that we have compromised our ethical response to our clients. It doesn’t help that our own egos get caught up in societally-identified worth, (ie., $) which we use to justify this compromised care.

    The answer is to take back your own profession and take leadership for reforming and defining the system. You have more power than you realize. After all, you are pretty high in the hierarchy and human food chain.

    • Leo Holm MD

      Totally misguided. Physicians do not go into medicine for the money. It is too hard, and there are many ways for “upper echelon” types like us make more money with a far better life. I would love to spend more time with patients. It is simply unallowable. It is not a matter of making money in Primary Care…it is a matter of covering overhead or not. In other words: sustainability. Not sure what you mean by “take back your own profession” or where one would even begin with that. Doctors are increasingly becoming employees and are overwhelmed by overhead, bureaucracy, paperwork and other factors that essentially amount to “process”. Who exactly do we take our profession back from? Insurance companies? Medicare? Large hospital systems? With what army? I assure you that the medical profession has little in the way of collective power or financing compared to any other entity in the health care system. The only people more disenfranchised than physicians are the patients.

  • MN

    Leslie – Right On! In addition we need to look at the “turf wars” that put up barriers between the different providers. Some of this is taught in school and some comes out as fear of losing what we could have had that went to someone else. Most of us got into the profession to help our patients, and then keep that focus. Know your limits and share with those who might better assist the patient. Medicine has it’s place but it will not teach a person coping skills or insight. Therapist (MFT’s and LCSW’s) and Psychologists have a place in practice as do Psychiatrist’s. We need to re-adjust our vision of the medical professions and educate the public accordingly. Too many ad’s on TV talking to the public about medications without proper education. ‘Talk to your Doctor’ and then they do and when pressured they get something, but not necessarily what they need. We all have to face the angry patient (sometimes within ourselves) and not fear the anger, embrace it and have the needed discussion with the patient who came to you as a specialist in your field. I have seen too many patients sent to a Therapist because the individual had an appropriate tear or got upset at the start of a conversation. The patient then negatively questions the initial provider then themselves and possibly the therapist they were sent to.
    The medical field needs to be overhauled and not glamorized as seen in TV. The providers need to be in charge (and as stated above be ethical in their dealings with their patients), not the insurance or managerial ‘bean counters’. Medicine is currently not a helping profession but an assembly line. We need to take responsibility for the mess it is in and for the cleaning up it needs

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    KevinMD is filled with articles today about the lack of appreciation monetarily for cognitive services versus procedural services resulting in a disappearance of general internists, family practitioners, pediatricians and psychiatrists who talk with their patients. As a referring physician I have a great deal of respect for all the psychologists and medical social workers who have filled that role but realize there is still a significant level of pathology out there that still would benefit from psychiatrists providing the traditional sessions plus pharmacological care.
    We should not be reducing specialty pay to compensate primary care and cognitive care fairly. We need to educate the public beginning at young age on the benefits of professional guidance and advice as opposed to more tests and procedures. Unless children grow up with this concept they will never get it as adults.

    • Fam Med Doc

      “We should not be reducing specialty pay to compensate primary care and cognitive care fairly.”

      My anesthesia buddy from med school makes between 350-400 K/yr. I’m barely making 140 K/yr in primary care.

      How would you suggest we diminish this impressive pay disparity?

      • Oda

        Why should we? I’m a specialist but not one with procedures so I make the same as a PCP. I don’t see any reason to punish the guys who make good money just because I don’t make the same. I choose my course knowing full well the benefits and drawbacks. This “soak the rich” attitude is very unprofessional.

        • Family Medicine Doctor

          dear oda,

          given you work with the same cpt codes as we do in primary care (i am making an assumption, please correct me if im wrong), changing the reinbursment given to these top paid specialists and increasing the reinbursement to primary care and the cognitive work we do will not hurt you but help you. I mean the cpt codes associated with certain procedures, not the ones associated with primary care. for example, anesthesiology has many cpt codes that a fam med doc, and you i assume, will never do. reducing those cpt codes will not hurt primary care, or you.

          another example: increasing a 99213 and 99214 would seriously help you, and I. Yet, it wouldnt hurt, or help, the specialist who do alof of procedures. Right?

          in regared to “soaking the rich”: i cant justify in my mind that an anesthesiologist is making 350-400 K and his/her primary care docs in that area are making less than 150K. is that what you mean by soaking the rich?

  • Tanya Gesek, Phd

    Where is psychology in the conversation. I would say that research is finally suggesting that medication is not the answer and that psychotherapy needs to be restored to the frontline of health care. Doctoral level psychologists are the best trained to do this work and move into the changing health care system as collaborators in accountable care organizations. We have the training in not only talk therapy (which works) but in supervision, program evaluation, assessment, and team building!

  • Rural PsyD

    From the perspective of clinical psychology in medical settings, I would offer this: “talk” is to therapy as movement is to surgery.

    If therapy were advice, if it were information or education, we would not be wrestling with this issue. My understanding of psychotherapy in medical settings is aimed toward health-related behavior change. Advising, informing, and ‘educating’ are not sufficient for behavior change for most patients. I believe reimbursement for ‘counseling’ covers these kinds of provider-patient interactions.

    There are many practioners, with a range of education and training, in the system whose ‘talk’ is reimbursed as ‘counseling.’ Low rates have to follow when one practioner’s advice is as good as another’s — when we all read from the same page so to speak. Let the nutritionist give some ‘tips’ on healthy eating or put the office nurse in charge of advising on increased adherence to regimen or let the physician counsel of smoking cessation. If information were enough. . .

    It might be more productive to make the conceptual shift to see psychotherapy, esp CBT (the most evidence-based approach in medical settings), as ‘procedural,’ not passive, and involving theory-based mechanisms of action, dose-response relationships, structural brain changes, and measurable outcomes — when performed with sufficient strength and duration for most patients.

    When we speak vaguely of ‘talk therapy’ delivered by psychiatrists, we lose sight that most medical patients whose health status would benefit from active intervention are not psychiatrically disordered and in need of a DSM diagnosis to improve their medical status. The CPT distinctions for behavioral health interventions and for psychiatric disorders are segregated for this reason, as I understand it. It seems to me that the fairly new behavioral health codes that clinical psychologists are able to use to provide interventions toward health-realated behavior change recognize that these interventions are active and procedural and require more than “counseling.” (I do not disparage counseling at all and only mean to point out the those patients who respond fully to ‘counseling’ interventions are not a problem.) Do physicians sometimes feel that ‘everyone’ is a physician?’ It seems to me sometimes that ‘everyone is a psychologist!’ All ‘talk therapy’ is not equal.

    I would like to see this distinction made in these sorts of discussions. The NYT article was also silent on exactly what ‘talk therapy’ entailed. Primary care patients will benefit from appropriate interventions which are active, ‘procedural’ and evidence-based. It’s not about patients feeling better, it’s about patients doing better.

    I appreciate this blog and learn from it regularly. This is the first time I have been moved to share my opinion. Thanks.

  • http://www.Singlemommyhoood.com Leah Klungness Ph.D. Psychologist

    This is an important conversation of particular concern to psychologists. Americans may want a test, procedure, or a prescription. But, if they want results for mental health issues, talk therapy is the most effective treatment —much more so than medication. This is the message that Americans need to hear. And policy makers need to incorporate into health care reform.

  • jim jaffe

    all of these arguments familiar, some compelling. question is whether paying cognitive docs more would somehow lead to better outcomes or a better system. clearly it would yield some more affluent primary care physicians, but that’s not an adequate reason for spending more money. would appreciate any evidence anyone cares to share that this would be a worthwhile societal investment.

  • http://georgehnorthrup.com George H Northrup, PhD

    I hope these conversations will likewise not go unrewarded. Here are a few of what I think are the relevant issues:
    –We overspend on healthcare (compared to the costs and results in other industrialized nations) but underpay some of our most critical health care providers.
    –There is no general prosperity on the horizon to solve this economic problem for us; indeed projections suggest that reducing the cost of aggregate health care will have to be a priority.
    –People who felt a calling to help the suffering find themselves preoccupied with reimbursement issues and then perceived as greedy or envious.
    –Enormous sums are spent on administration, corporate profits, and advertising. The Accountable Care Organizations envisioned by last year’s health care reform act have no defined corporate structure, so whether they will be provider-owned partnerships or for profit conglomerates with deep pockets for lobbying remains to be seen. I am deeply skeptical that the trend toward bigger and bigger health systems can be more efficient than the traditional private practice model. But it certainly consoldates power and creates economic opportunity for some.
    Along with discussions like these, we need our professional associations to think beyond their own self interest and to work together for the general well being of our patients. It is not unreasonable to expect that this goal presupposes appropriate compensation for our efforts.

  • http://www.drbarbarafontana.com Barbara Fontana, PhD

    I agree that reimbursement rates should reflect the cognitive skills used by primary care physicians when seeing patients and compensate them for this. I am appalled that they are not paid decent fees for what they do but not surprised given that insurers are profit driven.

    What is missing from this conversation are some very important research findings:
    1. the large medical cost offset that occurs when people’s mental health needs are addressed – they get sick less and use less health care dollars;
    2. BOTH psychodynamic psychotherapy and cognitive behavioral therapy are very effective in treating emotional problems;
    3. 70% of scripts for psychotropic medications (for depression, anxiety, etc) are written my primary care physicians – they are on the front line trying to treat emotional problems
    4. talk therapy works BETTER than medication to treat depression and other conditions according to research but MDs often just write scripts rather than advising patients to go for talk therapy…nice for the drug companies but sad for all the people who could be helped without medication.
    5. medication treats symptoms, talk therapy helps people understand and resolve the underlying issue/s causing the depression or anxiety, etc.

    Bottom line: talk to a psychologist because psychotherapy works…the side effect is a better life!

  • http://www.SeekingHealth.com Ben Lynch ND

    Excellent article.

    Healthcare system has it backwards and the insurance system as well.

    Insurance companies pay specialists more and generalists less.

    However, if generalists were paid to educate their patients, then there would be less visits to specialists because of prevention through education.

    The potential cost savings insurance companies would experience is massive.

    Think about it:
    - Patient is depressed.
    - ICD9 code noted and patient put into standard of treatment.
    - Rx drug. No talk therapy or discussion with patient.
    - Drug doesnt work because for numerous reasons.
    First, doctor has not identified cause of depression.

    Second, countless nutrient deficiencies exist in the depressed person.

    Third, the individual is not deficient in Prozac or other medications. They are deficient in social interactions, nutrients, family life and healthy food.

    - Rx a new drug. Doesnt work.
    - Then a new drug. Doesn’t work.
    - ‘All in your head’ diagnosis comes to play.
    - Due to ineffective depression ‘treatments’, patient now progresses over the years with conditions caused by untreated depression: over-eating, high blood pressure, obesity, diabetes, kidney failure due to countless meds and diabetes, unemployment due to disability leading to welfare.
    - Cost of all that compared to what it costs to evaluate the patient, engage in an active discussion, isolate the cause of depression and remove it?

    Meaning of Doctor = to teach.

    Insurance companies have replaced that defintion to:
    Doctor = identify patient’s IC9 in 5 minutes then prescribe drug or medical procedure that is standardized for that ICD9.

    This is why I don’t practice.

    People are seeking information desparately and they do not get it at the doctor’s office. So they turn online and get massive misinformation due to countless pathetic heath information websites. Shoot, WebMD is merely a billboard for pharma.

    If we are to change this, get paid for our knowledge and HELP people, then we will get online via blogs, websites like this, video, podcasts, books, ebooks and do what we can to actually provide effective health information.

    The only way to change this is to get out of the system. Don’t play the game.

    Develop a new model that will benefit not only the patient, but you as well.

    • jim jaffe

      while this has a certain internal logic, I’m looking for evidence to confirm it. seems it would be easy enough to pay primary care guys more in a single town and watch what happened to health spending in subsequent months and years. odd that no one’s tried that, far as I can determine. Primary care docs I know say they’d like more money, but also say they’re working full time and think there’s a shortage of their speciality (I remain agnostic on that one). but if its true, paying them more won’t lead to longer visits. If a doctor is seeing 40 patients in an eight hour work day now, the only I know of to increase the average 12 minute visit is to reduce the number of patients seen. that means longer queues for primary care doctors. are y’all suggesting it would be good policy to lengthen both average visit time and queue length. possible, but I’d like to see some evidence on that one as well.

      • Michael (chiropractic medicine student)

        Again i think AMA is over their heads. Problem is the AMA want to monopolize everything health care. From cognitive help to primary care. This is how i see it, let chiropractic physicians, naturopathic physicians and clinical psychologists help out. Really i feel a clinical psychologist (with prescription rights) can do what a psychiatrist does for a fraction of the cost. And i also see chiropractic and naturopathic physicians (with prescription rights) filling in as primary care physicians. If we can all embrace all facets of health care professionals, then maybe primary care physicians can stop whining about work load and little pay. If they do not like what they do, they should go back and specialize in something else and let other types of physicians take over that aspect of health care

  • http://www.drjoe.net.au Dr Joe

    The situation is similar in Australia. “Practical” skills are rewarded more than cognitive skills.Maybe because they are more visible? In Australia it reflects a time when there were few procedures done and none of todays technology so the payments schedule still reflects the practice of medicine in the 1950′s

  • http://expatdoctormom.com/ Rajka Milanovic Galbraith

    Thank you Richard for a great post. I agree with Linda in that so much more time is spent in follow up with every patient. I had always dreamed of opening a “boutique” practice and set myself apart by going the extra mile. The extra mile which now with rising overheads etc doesn’t pay. I have never not gone the extra mile but wonder what will it take.

    I would love to be paid for what I am worth but clearly did not go into family medicine because of the money.

    It will be a sad day if I am ever forced out of medicine (I prefer being self-employed) as practicing medicine is so fulfilling (the patient side of it!) and what I am most passionate about next to my family. I fear this may be sooner rather than later. In 1997, I joined a wonderful practiced that folded in 2001 after 30 years of being open. It was truly one of the remaining “mom and pop” shops. Then in 2009, I joined an independent group that was banded by management (meaning you paid your own overhead). I have never made so little money in my life! Unfortunately we were taken back abroad with my husband’s job or maybe this was fortunate. So now I am rethinking my next step for our return back to the USA late 2011/2012.

    Thanks again! Rajka

  • http://Www.healthyworcester.com Sherry Pagoto

    Psychiatrists are not talk therapists, they do not have extensive training in this, why do we want to pay them more to do it? Clinical psychologists are trained exclusively in this role, all 6 or so years of are graduate education is focused on this skill, not pharmacology. Psychiatrists shouldnt expect to make $150/15 mins of talk therapy ($600/hr), when as psychologists can’t bill nearly this amount (more like $150/hr at best). Talk therapy IS paid for, the problem is MDs are paid so well, they aren’t interested in making the kind of money it bills out. If we are going to talk about paying MORE for talk therapy, we should be talking about paying psychologists more for their time. Their annual income is a fraction of an MD.

  • anonymous

    This is one of the first articles on Kevin MD I can really get behind. Sadly, one of the most cognitive specialties is left out!
    Why arent we chiming for psychologists, not just psychiatrists to get paid more? Because they didnt attend med school? Do they not do 100% cognitive work?

  • http://getaheadwithdrg.wordpress.com psychmd

    I’m a psychiatrist. I have to admit my bias against psychologists, although I have a lot of respect for them. It’s not just that they didn’t go to medical school, but they didn’t go to psychiatry residency. The training they receive is very different. I just finished residency 2 years ago, and I know that my program was the exception, but my training was very therapy-heavy. To me, good therapy is psychodynamic, not cognitive behavioral, which is what psychologists generally focus on. I consider cognitive behavioral therapy, supportive therapy, etc. to be band-aid therapies. They work, but only temporarily. Not everyone is a good candidate for more intensive therapy, however, so these “lighter” types of therapies have their place. I would like to emphasize though, that to learn how to do those types of therapies, is not very difficult, and generally can be done by following a manual. That’s not real therapy to me.

    That’s my two cents about psychologists. I won’t even start about social workers, nurses, and PsyD’s, who also are able to perform therapy and bill for it. Their training unfortunately is generally even less–however they do have their place, and they do help a lot of people. But is it real therapy usually? No.

    Not intending to be harsh, but I think that’s the reality. I don’t really have an opinion about who should be paid what, although I think it’s an injustice as a general rule that med mangement pays more than therapy.

    • http://www.healthyworcester.com Sherry Pagoto PhD

      Cognitive behavior therapy a bandaid? And medication is NOT? Come on! It’s the ultimate bandaid. Symptom management is not a cure by anyone’s standards. Psychodynamic therapy is the best therapy? Show me the evidence. I think you’d be hard pressed to find a single systematic review supporting an advantage of psychodynamic therapy over anything cognitive or behavioral therapy for virtually any disorder. You might also check out Fournier et al 2010 meta-analysis that revealed antidepressant medications are largely INEFFECTIVE except for severe forms of depression. I don’t think your bias is against psychologists, it sounds like it is against evidence-based practice (perhaps because therapy training in psychiatry is 20-30 years behind the times). If MDs want to get paid to talk, I should hope they actually use evidence based practices!

  • http://getaheadwithdrg.wordpress.com psychmd

    I love the passion. But don’t presume to know what I know and what I don’t. Of course I know that short-term use of medications is also just temporary treatment, and a lot of times not necessarily the right treatment. I also know that most studies show the that CBT is efficacious, and that medications are equal in efficacy to CBT, and for most illnesses and populations medications + therapy is more efficacious than one or the other. The problem with the therapy studies is that what gets funded is CBT–because most of the studies show that patients can get treated with 13 sessions or less. Unfortunatley that’s a function of money–insurance companies love time-limited therapy, and therefore CBT studies get funded over psychodynamic therapy studies. WHich means there’s not a lot of evidence for dynamic therapy.

    Furthermore, none of the studies (medication or therapy) are longterm. So we don’t have evidence what is and is not a “bandaid” treatment. We just have a lot of anecdotal evidence and experience. I’m fairly young in practice, so a lot of what I was taught was from experienced psychodynamically trained psychiatrists. It’s a lot of theory with practical application; little evidence. Doesn’t mean it doesn’t work.

    Finally I think you’re taking the Fournier study out of context. The big conclusion from that study is that medications are about as efficacious as placebo. Not that medications don’t work. We are starting to learn how it is exactly that antidepressants work, and we’re finding more that they actually make longterm neurosynaptic changes in the brain–as does therapy, surprisingly (or not). Regardless, the standard of care is still to treat with medications, therapy, or ideally both. It would be considered malpractice for a physician not to offer a depressed person medications as one possible treatment option.

    I practice as much evidence based medicine that I can, considering the limitations within the current available research. I hope that within my career there’s more specific evidence for treatment for all sorts of psychiatric illnesses.

    I think it’s great that people care so much–hopefully we get better answers over the coming decades.


      I’m just a finance guy, not a shrink but this comment from PSYCHMD scares me: “Finally I think you’re taking the Fournier study out of context. The big conclusion from that study is that medications are about as efficacious as placebo.” It suggests that it is a success to have your treatment be equal to that of a Flintstone vitamin!?!
      As someone who is not in the medical field I would think a study showing medications are only as effective as placebos would mean they don’t work and if you would be willing to prescribe a medicine with results only as good as a placebo I think you become part of the problem of an overmedicated population. As a patient I would expect better than a sugar pill from my Dr. and think that people would benefit if ALL health professional worked together to help the patient. I think to improve we need to Be more open minded to Ideas other than your own.

  • http://georgehnorthrup.com George H Northrup, PhD

    Infighting doesn’t help us. I’d rather see all of us in mental health as colleagues. There are indeed many psychodynamic psychologists, though graduate training programs are increasingly favoring cognitive behavioral approaches. For a wonderful review of the efficacy of psychodynamic therapy see Jonathan Shedler’s articles last year in the American Psychologist and in Scientific American.

  • http://getaheadwithdrg.wordpress.com psychmd

    Agree with George–though I really like hearing what people have to say, which seems to be easier in a forum like this than in person. I can’t imagine any of the psychologists that I work with saying this stuff to my face, and I do want to hear what’s out there in people’s thoughts.

  • anonymous

    I agree with George. Infighting does us no good.
    However, I’d still love to hear why psychologists should not be treated as a “cognitive doctor” when someone such as a PCP is treated as one?

  • anonymous

    When its all said and done, post bachelors’s degree,
    my training (all in clinical psychology) will be 7 years of PhD work, (including of course, my own dissertation), 1 year internship after that, and at least 2-3 years after that working on getting my license, and qualifying as a specialist.

    That said, I’m rather tired of MD’s in general (not necessarily psychiatrists, because I tend to like psychiatrists) throwing out the “training” argument. Its tired and worthless.

  • http://getaheadwithdrg.wordpress.com psychmd

    So…I really wasn’t trying to comment on how much various providers should get paid. I know that psychologists have extensive training. I guess my bias is against the type of therapy generally practiced by psychologists, which happens to be CBT. I know and believe that some psychologists are very good at psychodynamic therapy–but it doesn’t seem to be the majority. Same with psychiatrists though–a lot of psychiatrists, if they perform therapy, also perform CBT. But I don’t think they should be paid as much for CBT than if they were doing more indepth therapy.

    Basically I think providers should be able to bill for type of services rendered. If a psychologist or psychiatrist is performing services that are more “in depth” then they should be compensated for them. I guess my whole point was that CBT is not as in-depth as psychodyanimic or even psychoanalytic therapy. I do believe it’s a bandaid therapy, just as are medications. The gold standard for treatment for mood and anxiety disorders is medication and therapy, but the type of therapy definitely matters.

  • Dr. Whited


    It really seems like you’ve been seduced by very convincing and experienced psychodynamic practitioners that their therapies are superior because they are more “in depth”. As someone else stated above, in-fighting doesn’t get us anywhere. The state of the science is that there is more evidence for Cognitive and Behavioral therapies being superior to psychodynamic approaches, than vice-versa. However, there is probably more evidence for equivalent efficacy of the empirically-based talk therapies. What we need to know most is what works best for whom.

    Your statements that psychodynamic therapy is more “in depth” (what does that even mean?), and efficacious in the long term is purely speculative and likely fueled by very charismatic and experienced practitioners who are trying to justify their approach in the absence of empirical validation.

  • http://georgehnorthrup.com George H Northrup, PhD

    I was the one who suggested we avoid infighting. Dr Whited, I invite you to look at Jonathan Shedler’s meta-analysis (mentioned above, in last year’s American Psychologist and in Scientific American). No one, whether psychodynamic or cognitive-behavioral, is entitled to make sweeping statements without having reviewed the evidence. Among Shedler’s findings was that the robust effect size of psychodynamic treatment continued to increase even after therapy was ended, while the effect size for CBT deteriorated with time. As many times as I’ve heard advocates of CBT tout its superiority, I’ve yet to hear anyone cite research establishing that. Indeed, reviewers like Barry Duncan, who have made a career researching efficacy, conclude that with very few exceptions (maybe snake phobias and DBT), there is no evidence for the superiority of any one treatment over another. Technique, in fact, accounts for a relatively small fraction of the variance in explaining clinical outcomes. I have not heard his take on Shedler’s work.

  • Tanya Gesek, Phd

    I think what we as psychologists should get behind is that psychotherapy in general enjoys tremendous support in the literature. There is great evidence to suggest too that CBT and psychodynamic approaches can both be employed and that the approach fit the issue. Bottom line is that psychologists have everything to offer and that medication is the true bandaid!

  • Dr. Whited

    Jonathan Shedler’s meta-analysis is certainly an important contribution to the literature, but it alone does not prove the superiority of any one therapy over another. Neither do single studies demonstrating the superiority of CBT over other therapies. As a whole, I am aware of more (a greater number) of studies demonstrating that CBT is superior to psychodynamic therapies. However, I feel that the MOST evidence exists for near equivalent efficacy of the empirically-based talk therapies, and their (at least) comparable efficacy to antidepressant medications. When the literature is taken as a whole I feel this is the conclusion we must draw and as a field we must pursue the use of empirically-based therapies.

    Dr. Gesek says this most succinctly. Not only does it benefit the field to focus on what talk therapy has to offer (as opposed to what one talk therapy has to offer over another), but if we make the public more aware of this and help put forth policy that supports it then we can reach more patients and treat them more effectively.

  • psychmd

    Couple of things–to MBFGMIKE, who was horrified by the idea that antidepressants are equal in efficacy to placebo, I would say don’t discount the placebo effect. All that means is that when a depressed patient is put on an antidepressant, 2/3 of the time he will improve (but 1/3 can be attributed to placebo). That’s still a fairly decent efficacy rate, and when you compare the risks of medication versus the risk of not treating, usually it is better to treat. The placebo effect is also not a secret, it’s something to discuss with the patient, while offering them the choice to take mediccation or not.

    The other issue to address, is that some on this forum are arguing about the efficacy of one therapy over another. I still maintain the stance that longterm psychodynamic therapy is better than most other types of therapy (including CBT, short-term psychodynamic tx, DBT, family tx and supportive tx)–there was a big metaanalysis in JAMA in 2008 that finds the literature supports this quite strongly.

    However, I also agree that in the big scheme of things, it doesn’t matter what type of therapy is better. Even though one therapy may be better than another, right now, what is paid for by insurance companies is short-term CBT, which (like medications) is helpful in the short-term. If it helps patients, and this is what patients have access to, then that’s great. But I think we shouldn’t fool ourselves and say that this type of therapy is superior to other types of therapy. I also believe the type of training required to perform CBT is easier–yes easier–than more intense therapies in several ways. Should it cost as much? No. And I think that’s whether it’s performed by a psychologist or psychiatrist.

  • psmillington

    Talk therapists (MFT, LCSW, PhD and PsyD psychologists) receive higher payment rates from insurers public and private because they use the therapeutic modality most effective in long term treatment.  The psychiatrists who only dispense medicines to patients rarely if ever communicate with the patient’s talk therapist about their mutual patient’s diagnosis and treatment needs.  If psychiatrists want more income, then they should provide more critical care services.  Otherwise, it might be a better public health strategy for all primary physicians to include a psychiatry specialization.   If all primary physicians were also licensed psychiatrists, then their income rates from insurers should be raised to par with other specialties. 

    On the other hand, there are situations when talk therapy is not the appropriate intervention. For psychiatrists to receive higher incomes their specialty training might better emphasize those urgent and emergent patient needs and confine their practices to more critical care medicine.

    Unless the patient informs the primary physician of the medications
    prescribed by their psychiatrist, the primary physician today may
    prescribe a medicine that is contraindicated for certain psychotropic
    drugs–and vice versa.  Another strategy to help prevent medication conflicts would be to enable pharmacists to charge insurers for individual medication reviews, for consulting and advising physicians, and for patient consultations.  I think something on this order is needed, but I doubt the AMA would ever allow it.

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