The erosion of psychiatric training has consequences

One of my most vivid memories of medical school was during my internal medicine rotation, when it had become apparent to me that, despite spending my pre-clinical years studying complex pathophysiology and pharmacology, and the fine art of history-taking and the physical exam, the actual clinical work seemed to be more like a numbers game.  I felt like I was always responding to a data point:  a blood pressure reading, a glucose level, a WBC count.  And the response always seemed to be the same:  I prescribed a drug.

To my immature medical mind, it seemed almost too simple.  I thought a computer could do it just as well.  When I commented to my attending physician that we seemed to be emphasizing medications over lifestyle changes, alternative therapies or preventive measures a patient might take, he responded, “We’re doctors.  We prescribe drugs.  That’s what we do.”

Fast forward about 10 years.  I now work part-time in teaching hospital.  One of my responsibilities is the supervision and training of psychiatric residents and medical students.  Recently, one of the students asked whether her final exam for the psych rotation would include questions about psychotherapy, to which my colleague responded (and yes, this is a direct quote), “No.  We’re doctors.  We prescribe drugs.  That’s what we do.”

The echoes of medical school resounded loudly.  But the words from med school professor had had a very different impact on me a decade ago than those spoken by colleague just last week.  While I accepted my professor’s words as the insight of a seasoned expert about what really matters in medicine, my psychiatrist colleague’s comments rubbed me the wrong way.

It made me wonder, has medicine changed?  Or have I?

I (and numerous others) have written extensively about how psychiatric drugs don’t work nearly as well, or as frequently, as advertised.  Others have written eloquently about the inherent dangers of psychiatric medication—a viewpoint which has been, at times, exaggerated, but to which I have become more sympathetic over the years.  These are two reasons to shudder at the fact that psychiatrists-in-training are being taught to emphasize the pharmacological approach.

But more important to me is the fact that, with comments like these, we psychiatrists are actively positioning ourselves to rely on a treatment philosophy that may well have run its course at some point in the not-too-distant future.  (Will today’s psychopharmacologists face a fate like those of the psychoanalysts of the 1950s and 60s?)  If students and residents increasingly see psychiatry as a pharmacology-oriented specialty, they will be less likely to explore other interventions that may ultimately prove to be more helpful to their patients.

Psychiatry is already ceding territory to other professionals.  Psychotherapy is taught in most psychiatric training programs, but few psychiatrists are paid (or choose) to do therapy.  Understanding how to provide systems-based care, or integrate psychiatric care into a patient-centered medical home (PCMH) model, is not something psychiatrists are trained to do, despite the obvious drift of American medicine in this direction.  Even some areas that could arguably be considered areas of unique psychiatric expertise— developmental disorders, addiction treatment, child development, geriatric neuropsychology, psychosomatic medicine, integrated pain management, trauma recovery, to name a few—aren’t a major part of the psychiatric curriculum.  Why not?  There are no drugs that we can prescribe (and, similarly, no drugs approved by the FDA) to treat these conditions.

This gradual erosion of psychiatric training has two consequences.  First, it opens the playing field to other mental health professionals who can generally provide their services more cheaply than psychiatrists do.  While most of these specialists perform their jobs quite admirably (making the psychiatrist irrelevant, by the way), the prioritization of cost over quality may result in patients getting worse care over the long run, especially if rigorous standards are not upheld.  Secondly, because meds are still where the money is, more non-psychiatrists are getting into the psychopharmacology game.  Psychiatric nurse practitioners (who have prescribing privileges), physician assistants, family practice docs, Suboxone jockeys, psychologists (in some states), and many others see psychopharmacology as a way to keep their patients satisfied and to keep their offices full.  When, in the end, the data show that these patients fare no worse (or, sadly, no better) than those seen by psychiatrists, then the writing will really be on the wall for most of us.

Some readers, particularly those working in a private practice setting, might respond, OK, I see your point, but some psychiatrists really do provide comprehensive, thoughtful care to their patients.  To which I would say, yes, but they are truly in the minority.  My own career trajectory (as well as my personal life) has taken some unexpected turns, and these turns have taught me how psychiatry is practiced among the masses in “the real world,” not in the Ivory Towers of Cornell, Stanford, or UCLA.  For the majority of patients and providers, psychiatric treatment is a numbers game, and the numbers are easy to follow:  More patients + More appointments per day + More medications prescribed = everyone wins.

I believe that not only can psychiatrists provide better care than the medication-laden treatments we dole out today, but we have a responsibility to do so.  Four years of medical school and four years of residency provide plenty of time to learn about human behavior, emotions, the roots of motivation, child development, family systems, learning theories, interpersonal skills, coping strategies, evolutionary psychiatry, ego psychology, personality theory, human sexuality, spirituality, existentialism, psychodynamic principles, and basically everything else that makes a person tick, in addition to the basic biology of the disorders we diagnose and treat.  To dismiss this in favor of a medication-oriented curriculum that could be obtained in a weekend seminar or in an industry-funded CME course, is an insult to our intelligence, and, potentially, the downfall of our profession.

When the prescription pad becomes a hammer, then every symptom starts to look like the proverbial nail.  Perhaps it’s time for psychiatrists to dust off some other tools before it’s too late.

Steve Balt is a psychiatrist who blogs at Thought Broadcast.

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  • Alison McKnight

    I totally agree with you. I think that there needs to be another aspect to medicine, and physicians should be taught in it. Physicians aren’t there just to prescribe medications, but to help people live a healthier life. While I’m not saying that people won’t benefit by medications, what needs to happen is that physicians should be a little more selective in who they prescribe to. A psychiatric diagnosis especially is something that can have longstanding repercussions, so the decision to prescribe should be made only after other things haven’t helped. Yes, depression does have its physical origins, but the truth is that most people who are depressed usually improve on their own without medical intervention. Sometimes all it takes to help someone get over their depression is to have someone that listens to them, and physicians can be one of these people that helps people realize that they are loved or they can be one more person that drives a depressed person over the edge. The reality is that people often want to take the easy way out, and I can tell you from experience that the path of least resistance is not always the best decision and the best decision isn’t always the easiest to make. I digress.

    I think that medication may be more effective when used in combination with other forms of therapy. The reason that they aren’t effective is that people’s lives don’t really change. They can still be emotionally and maybe even physically isolated from other people, even after medication. People should be encouraged to partake in social events and to change their lives for the better. Better ways of dealing with stress need to be presented to these people, and these people need to have a place where they feel they are listened to. If this is left to the physician, then so be it. That is something that we can deal with. 

    I just want to end with my own personal story. I have been dealing with depression and schizophrenia symptoms since I was in my teens (I’m now in my early twenties), and I have used many resources to try to overcome these symptoms, none of which proved very effective. I felt pretty powerless over the symptoms I was experiencing. It wasn’t until a few months ago (when these symptoms were starting to control every aspect of my life) that I had considered getting treatment through psychiatric medications. However, after getting treatment, I feel better and in control of my symptoms rather than being the other way around. I think that medication has helped me and can help others as long as physicians are especially selective of who will be prescribed medications and who will undergo other treatment. Then again, we need to keep in mind that medications alone may not be effective enough and that sometimes the best thing we can do for patients is to give them our time. 

  • Jon Nixon

    “Suboxone jockeys”? What a slur, man. Do you need to come out and say something?

  • Michal Haran

    What you say is sadly true not only for psychiatry, but for medicine in general-too much medications and too little true comprehensive and thoughtful human care. 

  • Anonymous

    You know your own field, but in my 22 years of family medicine, it is the pretty much the drugs that have helped.  Examples:  Inhaled steroids for asthma:  I virtually never see a horrible asthmatic anymore. Remember theophylline?  I’m trying to forget. 2. Dyslipidemia medications: heart attack rates have gone way down.   3. Diabetic meds: A1cs are getting better all the time.  4. Proton pump inhibitors–much much better than the old H2-blockers, not to mention surgery (!) for peptic disease, virtually unheard of now. 5. Even in primary care psych, the SSRIs are much better tolerated than the old meds.
    As a family doc, I can say that I’m a drug prescriber and proud of it. My patients are better off for it.

    • Anonymous

      Oh, I almost forgot, and what about impotency meds?  Men (and women) have benefited greatly. 

  • Justin Garrett

    Quote from the article: “To dismiss this in favor of a medication-oriented curriculum that could be obtained in a weekend seminar or in an industry-funded CME course”

  • Justin Garrett

    Quote from the article: “To dismiss this in favor of a
    medication-oriented curriculum that could be obtained in a weekend
    seminar or in an industry-funded CME course”.  I think this statement is a gross oversimplification of psychiatric medication prescribing. 

  • Anonymous

    Much agreement from me.

    Those who financially benefit from a way of practice will defend it vigorously.

    Ambulatory psychiatric practice has turned into assembly line widget processing.  20-25 patient a day is the new norm.  Why?  More money.

     The $$/minute are significantly higher for a 90862 than a 90807.  So, we have convinced ourselves that we can now listen faster.

    There’s not enough time for careful, thoughtful diagnosis (and many psychiatrists use the non-timebound quality of a 90801 to do initial evals in 30 minutes or less.)

    We, along with the pharmaceutical industry, have progressively painted an expectation that we can cure misery with a pill.  This raises the magical hopes of those wanting quick relief with little effort, keeps the drug companies happy, and puts my kids through college.

    I say I can fix misery with a pill.  Patients come to see me for that fix … and not to learn a different way of living life.

    Add to that third party payers’ requirement s for diagnosis to cut checks (there’s no “well” psychiatric visit) and we have a mess.

    Psychiatrists feel pressure to see people briefly, diagnose everybody, and prescribe to everybody (to meet the expectations we’ve set … and because that’s the only string left on our guitar).

    THAT is modern psychiatry.

    I now prefer working only with the severely mentally ill.  There’s no ambiguity re: need for medication or diagnosis.

  • Anonymous

    I just submitted 392 pages of medical records to a Medicare auditor because a computer “probe” showed that I billed Medicare much more than the average psychiatrist for Psychotherapy with (and without) medication management (CPT codes 90807 and 90806). The average psychiatrist apparently only perfoms this service with med. management 26 times per 100 patients in a 6 month time period. That makes me and any other psychiatrists who regularly provide psychotherapy to our patients “outliers” who will be subject to such burdensome audits, having to justify the medical necessity and virtually every other clinical feature of the patients involved in these sessions. It’s yet another reason to deny such care to patients. Not a good trend! 

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