The decision point psychiatrists faced with psychotherapy

There’s been plenty of buzz about a recent New York Times story, “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy” by Gardiner Harris. The story is essentially a profile of Dr. Donald Levin, a 68 year old psychiatrist who has a private practice in Doylestown, Pa.

It is a poignant example of a common situation in psychiatry. Older psychiatrists were trained during a time when there were few effective psychiatric medications, so they cut their teeth on training in psychotherapy. Not surprisingly, doing therapy is fun–it’s involves getting paid for having interesting and intimate conversations with people, and helping them to become happier as a result.

In the old days, psychiatrists were paid very well for therapy. In part, this was due to the law of supply and demand–until the late 1940s, psychiatrists alone were allowed to do psychotherapy. But with World War 2 came a critical demand for more therapists to deal with the psychological needs of veterans. Over the ensuing decades, the NIMH granted funds to train psychologists and other non-MDs to deal with the growing public demand for therapy. As the supply of therapists rose, reimbursement for therapy plummeted.

Of course, as any professional guild must do, the American Psychiatric Association fought this trend ferociously, arguing that only professionals who received medical training had the qualifications to do therapy. In 1949, the president of the APA summarized the opinions of a special “Committee on the Relations of Psychiatry and Clinical Psychology” by saying that the “American Psychiatric Association is strongly opposed to independent private practice of psychotherapy by the clinical psychologists; and The Association believes that psychotherapy, whenever practiced, should be done in a setting where adequate psychiatric safeguards are provided.”

To the modern eye it seems absurd that intelligent people could believe that you had to go to medical school to do psychotherapy, but the potential for loss of income often confuses the mind. From the 1950s until the 1980s, the APA continuously lobbied state legislatures to prevent independent credentialing for non-MD therapists, but they eventually lost in every state.

Ironically, many within the APA were eventually happy to off-load their therapy tasks to psychologists and social workers, because a plethora of psychotropic drugs were introduced in the 1980s and 1990s. Psychiatrists no longer needed to do therapy to make good money. But this forced a decision point for many psychiatrists, like Dr. Levin, who loved doing psychotherapy. Would they continue to do psychotherapy–thereby diminishing their incomes–or would they become psychopharmacologists, lucratively churning through patients in 15 minute increments? Dr. Levin chose the latter, and sadly, he is unfulfilled.

Quoting from the New York Times article: “I miss the mystery and intrigue of psychotherapy,” he said. “Now I feel like a good Volkswagen mechanic.” “I’m good at it,” Dr. Levin went on, “but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.”

Many psychiatrists will recognize the sense of tedium and boredom described by Dr. Levin. He went through psychiatric training to do therapy and is now a pill-pusher.

Of course, one can argue that he is simply living with the consequences of that age-old decision: the choice of  higher income, but less fulfilling work. The world is filled with realtors, lawyers, marketers, managers, etc…, who wish they could make their current income doing watercolors or teaching elementary school or writing novels.

If Levin wanted to do therapy, he could, but, as he said in the article, “Nobody wants to go backwards, moneywise, in their career.” We all make our decisions.

 

Daniel Carlat is a psychiatrist and author of Unhinged: The trouble with psychiatry- a doctor’s revelations about a profession in crisis.

 

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  • http://natickpediatrics.net Rob Lindeman

    Agree. I don’t feel sorry for Dr. Levin. It sounds, from the article, as if he doesn’t WANT to do psychotherapy any more.

  • Smart Doc

    Interestingly, even the psychologists don’t want to do psychotherapy anymore. The American Psychological Association is busy lobbying to get their social science PhDs recognized for medication prescribing privileges.

  • Elizabeth

    I think the unspoken thing in this, and many, articles is that one can still practice therapy and get paid for it well, just not by insurance companies. And yet another difference in access to care emerges.

  • horseshrink

    Re: “the potential for loss of income often confuses the mind”

    During private practice days, I had a spreadsheet populated with CPT codes, their Medicare allowables, and calculated $$/min. No genius required to determine that the $$/min for a brief appointment = much higher than for a long appointment. 90807 was a great way to lose money for a practice.

    So … psychiatrists run faster on a hamster wheel they helped to create in order to maintain the incomes they desire.

    20-25 patients a day is the new norm.

    How fast can a patient talk?

    How fast can a psychiatrist listen?

    How do we rationalize our new financially driven productivity norm, to which we’ve become habituated – boiling frog style?

    Did the complexities of the human story and their impact upon symptom expression and clinical outcome become less important because of our need to maintain a certain income?

    Are we losing credibility in the public’s eye as a result?

    • Anne

      “Are we losing credibility in the public’s eye as a result?”

      Yes.

  • Leah Thronson MD

    I had very wise mentor in medical school, Dr. Lawrence Putnam, who would not allow us (third year med students) to do anything except talk to a new patient for 90 minutes -not even take notes. Then we reported to Dr. P the differential diagnoses, confirming tests that we thought were appropriate (including just using our stethoscopes and taking blood pressure), possible treatment plans, hoped for outcomes and so on. “Listen to your patient, they will tell you the diagnosis” said Dr. P. I still spend 90 minutes minimum with new patients and no less than 30 with followup patients (typically more like 60 and occasionally 90). I see most of my patients weekly and never do med management only. Patients are far too complex for me to imagine that I could do my job adequately with a 15 minute visit every week, let alone every 3-6 months. Therapy with or without medication has been repeatedly shown to be the best treatment. Don’t fax or call prescriptions either and don’t make much money. Patients often seek me out because the don’t like being “cattle not people”. May not make big money but my practice is always full. Ask yourself how you feel as a patient when your doctor spends only 15 minutes with you. Before and after recent surgery my orthopedic surgeon spent 45 minutes with me and my family. Guess what? I refer everyone to him, and his incidence of malpractice complaints goes down significantly (well documented) with every minute he takes the time to listen to his patients. Leah Thronson MD Psychiatry

  • Sideways Shrink

    With no office staff or answering service my yearly operating expenses are around $45,000. About half of this is student loans which one would have to count as operating expenses becauses without my license I could not operate. I don’t do 15 minute medication checks ever; I take private insurance; I do mostly hour long psychotherapy visits except for my cohort of ADD patients who I see for an hour a month to see if they are following through with the goals they have set for themselves.
    Having read the article, the difference between
    myself and someone like Dr. Levin is that I do not and will not ever have a big stock portfolio to lose in the market and then have to keep working to save money to retire. For shrinks and primary care in my generation with our student loans we just want to pay off our student loans, get our kids through college, do some meaningful work along the way and retirement? That is for the Baby Boomers. I don’t think much will be left after that.

  • Sideways Shrink

    I would like to restate that with self insured health insurance premiums, my overhead is actually $65,000.00 a year. There is a humorous equation: my mortgage=my student loan payment=my health insurance premium.

  • Oz

    The question is, why should psychiatrists even bother with psychotherapy? there’s nothing in medical school teaching it, and to my knowledge, it’s not part of a psychiatrist’s residency. There’s no reason a doctor will be more qualified than a social worker or a psychologist. And quite frankly, evidence of benefit is so shady, so that’s for the best