Are psychiatrists rushed, uncaring, and in it only for the money?

Perhaps you’ve heard the news: psychiatrists no longer have time to listen to their patients.  It’s all about writing prescriptions for medications and the days of “tell me about your mother”  are long gone, or so we’re told.  The current perception is that large volume practices where patients are seen in a matter of minutes are now standard and acceptable in psychiatry; that it’s how many — if not most — psychiatrists practice, and that medications and psychotherapy are either/or  treatments, rather than complementary.

Is it true that psychiatrists are rushed, uncaring, uninterested, and in it only for the money?  Has it all become about  how fast a prescription can be written, as if the practice of psychopharmacology is something that can be done quickly, thoughtlessly, and without even knowing the patient?  As a past president of the Maryland Psychiatric Society, a former community mental health center medical director, and a general extrovert, I know a lot of psychiatrists.  I was curious, and with some help, I put together a How We Practice survey and had the Maryland Psychiatric Society send it out to the members who have email addresses on file.

Psychiatrists were asked how many people they typically see on their busiest day of the week — please note that this survey was not validated, and data were not collected: it was merely a question we asked in an email survey.  The most common answer was 8 to 11 patients. Of the 16% of respondents  who report they see more than 21 patients in a day, several noted that they work in settings other than outpatient practices: hospitals, group homes, addiction centers, schools, and settings where patients are seen in groups or with the help of a multi-disciplinary team.  Only 10 psychiatrists saw more than 30 patients on their busiest days.  We concluded that in Maryland,  few psychiatrists have very high volume outpatient practices, or perhaps those who do are too busy to take a survey.

Some patients do very well seeing a psychiatrist for 15 minutes a season (once every three months) and psychotherapy is not necessary. That’s  not always the case and we know that many patients do better with a combination of psychotherapy and medications.  There are patients who may do better seeing a single psychiatrist rather than dividing their care between mental health professionals.  Sadly, the insurance industry reimburses best if patients are placed on a conveyor belt to see their psychiatrist. That doesn’t make it good medicine, and even when patients get better, some are dissatisfied and angry.

There are several reasons why psychiatrists may practice outpatient psychiatry in a rapid-care model. Participating with insurance plans is a socially responsible thing to do and there are regions of the country where there are very few psychiatrists and restricting practice size is just not feasible.  Also, it pays well.   That doesn’t make it good medicine, nor does it mean that everyone’s doing it. There is no one-size-fits-all psychiatry.

Many psychiatrists (70%– per Mojtabai and Olfson in the Archives of General Psychiatry) see patients for psychotherapy — if not all their patients, then at least some of them.  And often psychiatrists who don’t practice psychotherapy still listen and evaluate a patient’s symptoms within the context of what is happening in their lives, then take the time to answer questions and explain their treatment recommendations.

Converyor-belt psychiatry works for some, but not for others, and it gives psychiatry a bad name.  It is simply not true that all psychiatrists practice this way, that psychiatry has given up on psychotherapy, and that it’s all about the medicines.  In a field that is hampered by stigma, this portrayal is both wrong and irresponsible, and discourages people from seeking treatment.  If that’s not bad enough, it also discourages doctors from pursuing careers in psychiatry, and that only worsens the problem.

Dinah Miller is a psychiatrist who blogs at Shrink Rap and co-author of Shrink Rap: Three Psychiatrists Explain Their Work.

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  • Matthew Mintz

    This is an excellent post and good follow up to your piece “Psychotherapy from the psychiatrist’s point of view.” You made it clear that it is the reimbursement system, and not the physicians causing the problem. It’s clear that you want to correct the media perception that most psychiatrists have stopped doing psychotherapy.  Though in your email survey, few psychiatrists appear to see high volume patients and in the one study  you quoted, 70% of psychiatrists see patients for psychotherapy; I suspect that neither stat represents actual psychiatric care in the US.  My guess is that few psychiatrists now take insurance.  These few psychiatrists do limited if any psychotherapy.  Though they are in the minority, because of their high volume, they probably account for more visits to a psychatrist then the non-insurance takers combined.  Thus, the media may be incorrect in their assumption that most psychiatrists have stopped doing psychotherapy, but they may be quite correct in stating that most patients who are referred to a psychiatrist get the psychotherapy from a non-MD/different person.  We currently have two forms of psychiatric care in our country: the one that people expect (from movies, TV, etc.) and the one you get if you use your insurance to pay for mental health. It is important that the public be made aware of this issue, because unless their are major changes to the way primary care physicians get reimbursed, the exact same thing is/has already started to happen to primary care.

  • Anonymous

    I wonder how representative the sample was.  I suspect the assembly line psychiatrists were excluded from the sample, in large part because they were unlikely to respond to survey emails (I wouldn’t have.)  At most you can opine that there are still psychiatrists out there who strive to see fewer than a dozen patients daily (and, thus, had time to respond to the survey.)  Unfortunately, they don’t seem to be present in sufficient numbers to counter a growing public perception otherwise.
     
    I know what my experience was in private practice.  I know what my colleagues did then.  I’ve no evidence that any improvement has occurred since then.  Dollars per minute were compellingly higher for brief appointments.
     
    As I contemplated re-entering private practice several years ago, a former community colleague (who wanted me to join his practice) told me with heartfelt pride how much he valued his patients … so much so that he, unlike others, actually spent 20 minutes apiece with them.
     
    He resolved any of my doubts with that statement.
     
    ***

    Re: social responsibility to accept insurance?  I disagree strongly with this.  The insurance company feels no such social responsibility and is glad to exploit any who choose to feel it.
     
    How far do you want to go with social responsibility reasoning?  Some would argue that it’s socially responsible to see as many patients per day as possible to try to compensate for psychiatrist undersupply, or to see underinsured people with brevity, since half a loaf might be better than none at all.
     
    I think “social responsibility” is more effectively realized through pro bono, reduced fee, charity organization, or government employed work.
     
    I also think we, as psychiatrists/physicians, need to be very, very careful with our professional treading into areas of “social responsibility” … and the next logical steps, social policy and law, lest we delude ourselves into thinking we know what’s best for society.

  • http://www.facebook.com/people/Nancy-Rubenstein-Delgiudice/631174512 Nancy Rubenstein Delgiudice

    I am a presenter at the ISEPP (International Society for Ethical Psychiatry and Psychology), my presentation title tells alot about my experience; “What about the survivors?”. I want to go on record here that not only do I find KevinMD’s posts misleading but also offensive. His evident compassion actually makes this worse. Instead of attempting to cover all the points I would like to make, I will content myself simply to state my disagreement with his last line. Discouraging people from going into psychiatry doesn’t make things worse; ending psychiatry as a profession is the real solution. Realizing that the audience reading my comment is most likely to take this as an unreasoned and “crazy” position….I urge you to spend some time with Mr. Google and familiarize yourselves with a very large and experienced grassroots movement (Antipsychiatry……not to be confused with Scientology, one of whom I am definately not), and visit websites like Mind Freedom International, Psychrights.org (I am Director of Public Education), ISEPP…..and last but not least CCHR (Citizens Commission on Human Rights, started over thirty years ago by Scientologists). Consider all the evidence before you judge. And good luck…..the Matrix has you.