Saturday, May 11, 2013

The Model of Psychiatric Care for the Future

The Psychiatric News came out with an article yesterday that is critically important for all psychiatrists to read.  It reveals the American Psychiatric Association (APA) thinking about the future role of psychiatrists and the model of care that they are promoting.  The diagram in this article titled "Integrated Care Relies on Team Approach, Consultant Role for Psychiatrists" is a critical read because it shows what is basically a managed care paradigm for marginalizing psychiatrists.  There is is a "BHP/Care Manager" between the psychiatrist and the patient.  This is a popular managed care approach to having "care/case managers" making discharge decisions for psychiatrists providing inpatient care.  For anyone with professional expertise and direct responsibility to patients it is unacceptable.  

The main reason that psychiatry has been marginalized is that all of the knowledge in the membership about what we do and the value we add is ignored in the face of special interest research.  The research that forms the "evidence base" for our marginalization in the Psych News article is a good example.  There is a long history of similar studies have been published to sell the managed care industry.  I can come up with a pharmacoepidemiology study from 20 years ago that show that putting everyone in a primary care clinic on fluoxetine saves money on as many parameters as this article claims for integrated care.  Instead of confronting that and saying: "You know psychiatrists do a lot more than that" - the APA seems to accept it and think  that integrated care is some big deal.   From the diagram it is clear to me that integrated care is just the latest head of the managed care hydra.

The other aspect of the article is the omnipresent "cost savings" rhetoric.  Professional organizations have bought this hook line and sinker and seem obliged to include that nonsense in policy about the future of their speciality.  The difference of course is that in the last two decades, Cardiology has built out a trillion dollar infrastructure being "cost effective" and we are now treating people in jails who should be in psychiatric hospitals, we have few functional detox facilities and have minimal resources to help disabled patients in the community.

What we need here is a reality based characterization of what psychiatrists do and on average it is a lot more than sitting in a primary care clinic and advising primary care docs about what to do if they can't get their depression ratings (PHQ-9 scores) headed in the right direction.  Its is just a matter of time before everybody who thinks they can make a psychiatric diagnosis by reading the DSM will think they can treat depression by reading an algorithm and psychiatry slips off the next managed care diagram.  Nobody will realize they just eliminated not just a psychiatrist but the person in the clinic who knew the most Neurology as well.

If we are going to promote any image of ourselves and an image that current trainees can be excited about, it should be a larger than life psychiatric multispeciality clinic and a group of psychiatrists who can cover the gamut of care.  That is consistent with the psychiatrist of the future that Thomas Insel, MD has talked about, and it takes a page from some of our specialist colleagues like Radiologists and Anesthesiologists.

They realized a long time ago that you are not going to get a fair deal bartering away your expertise for the sake of doing business.

George Dawson, MD. DFAPA

Mark Moran.  Report on Health Care Reform Focuses on Psychiatrists' Role.  Psychiatric News May 3, 2013.


  1. Dr. Dawson, thank you for writing about this important topic. As a child psychiatrist, I really worry about the impact of managed care on my profession, given the relative shortage of child psychiatrists around the country.

    While I don't agree with everything you write, I'm glad to have found a blog with a different perspective from the usual ones (including my own) that are fairly critical of mainstream psychiatry.

    1. There is no better example of the negative impact of managed care on the provision of psychiatric care than child and adolescent psychiatry. One of my best training experiences as a medical student was a course in infant and toddler psychotherapy for children at risk in Milwaukee. It occurred in a day hospital run by two psychiatrists, a fellow, and three medical students. We saw children and their parents individually, in groups, and in their homes in the case of parents who were too disabled to come out to the county grounds. This was all psychotherapy and we had a seminar once a week where we reviewed the latest information in scientific journals. We saw kids who were diagnosed with "autism" completely change their behavior. I haven't treated any children in over 20 years at this point but my guess is that nothing like this exists anymore. And anyone espousing the managed care model will tell you why and tell you how things are supposed to be done.

      No therapy, no detailed assessments, and no good residential treatment for the kids that need it. The state where I work had a solution where doctors prescribing antipsychotic prescriptions to kids could get a second opinion from a child psychiatrist. I guess that is more "cost effective" than a rich clinical atmosphere and a comprehensive approach to children and their families.