Nice Survey - Wrong Conclusion

There is a survey study of ease of getting and appointment with a psychiatrist in this month's Psychiatric Services.  The researchers called psychiatrists offices in three major cities in order to get an appointment.  They wanted to assess the degree of difficulty and whether or not payer source would be a factor.  Of the total calls only about 25% resulted in an appointment.  The reasons are listed in two tables in the article that is available on line.   Interestingly  there was no big difference  between private pay payer sources and insurance or Medicare in terms of getting appointments.  Given the movement of psychiatrists out of employee systems and Medicare based systems that was surprising and suggests to me a possible sampling flaw in the study or an artifact of the low return rate.  The flaw could be that the researchers looked at a Blue Cross Blue Shield (BCBS) web site and called lists of in-network providers in Boston, Houston, and Chicago.  The authors in this case do a reasonable job analyzing their limited data.  In their discussion of possible solutions they fall short of possible solutions.

In this case a key assumption is that the inability to set up appointments with psychiatrists implies there is limited access and this in turn means a shortage of psychiatrists.  We are hearing this argument at a time when managed care organizations like BCBS are basically saying that patients can receive psychiatric care in a primary care clinic.   In fact, BCBS was one of the early adopters of the PHQ-9 based Diamond project, where PHQ-9 scores formed the basis of a depression diagnosis in primary care clinics and the focus was optimizing antidepressant prescriptions based on those scores.  Where does an appointment to see a psychiatrist fit in that type of care?  Does collaborative care mean collaboration with a psychiatrist for every 500 or 1,000 or 10,000 primary care patients with an elevated PHQ-9 score?  Are patients in systems of mass care likely to seek psychiatric consultation?  In many algorithms of similar integrated care, some systems are set up to avoid psychiatrists completely, including the psychiatrist who is doing the psychopharmacological consultation.   How would such a system of care bias patients against psychiatrists and would psychiatrists be more dependent on other referral sources? And most importantly, wouldn't we expect limited access to a group of psychiatrists designated as in-network providers for a managed care company?  This is after all what managed care companies do.  They provide disincentives for physicians to see patients.  Managed care is a rationing mechanism.  It does not surprise me at all that physicians operating in that environment are difficult to see.

The authors propose that there are a number of ways to get medical students interested in psychiatry and that this would potentially solve the problem.  I don't know how that would work if there are already psychiatrists out there who are either working too hard or not interested in seeing new patients or referrals.  There was also the issue of psychiatrists being listed with incorrect phone numbers in over 10% of the cases.  It would also be interesting to note if the psychiatrist contacted agreed that he or she was actually in the network of care being described.  Many psychiatrists have told me they were in networks or panels that they had never agreed to participate in.

As I have previously stated, I don't think it is a question of recruiting more people in to psychiatry.  That approach ignores the state of crisis that the field is in right now.  That crisis involves the government and managed care companies dictating what psychiatric care is.  It also involves the American Board of Medical Specialties dictating what they think psychiatrists need to do for ongoing professional education.  It involves professional organizations - both the American Psychiatric Association (APA) and the American Medical Association (AMA) abandoning their member practitioners for what appears to be short term political gain.  The first thing lost to the politicians and businessmen  has been the practice environment.  Being a physician is more and more like being an assembly line worker.  Physicians are accountable to managers with no medical knowledge and no professional standards.  All of these developments have clearly demoralized physicians.

Taking a look at one of the suggestions, an interesting one was the suggestion that exposure to psychodynamic therapy increases medical student choice of psychiatry as a speciality field.  There are a few problems with that theory that are consistent with the deterioration of the practice environment.  It is certainly unlikely that any trained psychiatrist would make their expected productivity numbers for employees by doing psychodynamic psychotherapy.  It is currently practiced strictly in private settings or as supplementary activity once the productivity expectations are met in other endeavors.  Some psychiatrists have a psychotherapy practice "on the side" of their main employment.  It is highly unlikely that hospital or clinic environments are psychodynamically informed settings anymore or that residents learn how to manage those problems.  Many of those environments are a set up for split treatment.  Using psychodynamic psychiatry to sell residency to medical students seems like an informed consent issue to me.   Sure we will train you in it and supervise you doing the therapy but good luck practicing it in the real world.  I could put together a program that medical students would flock to, but they would never be able to use what they learned in a dumbed down practice environment.

You cannot have a profession that allows itself to be defined by hack politicians and businessmen with their own for-profit agenda.  Unless organized medicine and psychiatry focuses on that basic element, everything else is rearranging chairs on the deck of the Titanic.  Successfully rationing care does not mean there is a shortage of doctors.  It may mean the doctors just find the cost of doing business with a particular insurance company so high that they would prefer to see fewer or no patients from that payer.

It is absolutely mind blowing to me that nobody else can see that.


George Dawson, MD, DFAPA

Ref:

Monica Malowney, Sarah Keltz, Daniel Fischer, J. Wesley Boyd; Availability of Outpatient Care From Psychiatrists: A Simulated-Patient Study in Three U.S. Cities. Psychiatric Services. 2014 Oct (early online release).

Suggested Changes to Psychiatric Residency Programs

I received an e-mail two weeks ago that asked for my suggestions on immediately reforming residency programs for psychiatry.  I had the experience of completing my residency in two different university based programs.  My residency occurred at the height of the controversy between the self described biological psychiatrists and the psychotherapists and psychoanalysts.  Although I have never seen it written about there was open animosity between the groups at times.  A biological psychiatrist back in the day might make a statement like: "I don't do talk therapy".  A psychotherapy oriented psychiatrist might refer to the biological types as "Dial twisters" referring to an approach that suggested excessive biological reductionism.  Apparently neither group had read Kandel's seminal article in the New England Journal of Medicine four years earlier and how plasticity can be affected by talking, medications, and of course other experiences.

Several years ago, I attended an anniversary of the University of Wisconsin Department of Psychiatry, the program I eventually completed my residency at.  Thomas Insel, MD was one of the invited speakers.   He outlined a revolutionary approach to educating psychiatry residents that involved a joint 2 year neuroscience internship with residents from neurology and neurosurgery.  He did not provide any details.  When I sent him a follow up e-mail two years later, he said it would probably not happen on his watch.  I can easily build on that theme.  I think that a two year program focused on basic and clinical neuroscience remains a good approach.  The current approach to getting the relevant information is haphazard at best.  It depends on lectures in neuroscience being interspersed with clinical rotations of varying quality and to a large extent it depends on the faculty.  How many faculty are there and how many of them are expected to produce managed care style billings or "productivity" rather than high quality teaching.

A comprehensive and integrated approach that will teach state of the art neuroscience and provide the relevant training in neurology and medicine is possible.  There are many obvious areas for improvement.  Residents often spend their time on clinical rotations of minimal relevance for psychiatrists.  I can recall learning ICU medicine and needing to familiarize myself with various tasks (Swan-Ganz catheters, central lines, ventilator settings, dopamine drips, balloon pumps) that I would never use again.  I needed to be seeing hundreds of people with heart disease, arrhythmias, hypertension, diabetes, other endocrine disorders and neurological disorders.  I saw many of those people when they were hospitalized, but seeing these folks in ambulatory care settings designed to enhance the learning experience for a psychiatrist would provide a better experience.   The process should probably start earlier in the fourth year of medical school.  Prospective psychiatrists should be focused on electives in neurology, medicine, and neurosurgery rather than psychiatry.

The teaching of psychiatry needs to address the practical concerns about diagnosis and treatment but also philosophical concerns.  Residents need to be familiar with the antipsychiatry philosophy and the existing literature that refutes it.  Residents need to know about the issue of the validity and reliability of psychiatric diagnoses and how that is established.  There is actually a rich history of how that came about but it could easily be summarized in one seminar.  One of the features that I was interested in when I was interviewing for residency positions was whether or not the program supplied a reading list.  There were surprisingly few that did.  This subject area would be a good example of required reading that is necessary to bring any prospective resident up to speed.

A good model to illustrate the difference between a neuroscience based approach as opposed to a symptoms based approach is American Society of Addiction Medicine (ASAM) definition of addiction on their web site.  Unlike the DSM collection of symptoms designed to pick a group of statistical outliers,  the ASAM definition correlates known addictive behaviors with brain substrates or systems.  Both of the standard texts in the field by Lowinson and Ruiz and the ASAM text by Ries, Feillin, Miller, and Saitz are chock full of neuroscience as it applies to addiction.  When I teach those lectures, I generally am talking about how medications work in addiction at that level but also how psychological and social factors work at the level of neurobiology.  I have not seen the DSM5 at this time, but I do think that it is time to move past defining every possible substance of abuse and associated syndrome and incorporating neuroscience.  Especially when the neuroscience in this case has been around for 50 years.   Residency programs need to teach that level of detail.

Psychiatrists need to maintain superior communication skills relative to other physicians and that means getting a good basic experience in interviewing and psychotherapy techniques.  At the same time - the psychiatrist of the future needs to be able to order and interpret tests including ECGs and MRI scans.  That wide skill base taxes every faculty except the very largest academic departments.  In the Internet age, there is really no reason that every residency program should not have access to the same standardized PowerPoints, lectures, and didactic material.  The ASCP Model Psychopharmacology Program is an excellent example of what is possible.  I would go a step beyond that and say that there should be a culture within organized psychiatry so that every psychiatrist should have access to the same material.  Establishing a culture where everyone (trainees and practicing psychiatrists alike) is up to speed and competent across the broad array of topics that psychiatrists need to be familiar with is a proven approach that is rarely used in medical education.

Psychiatry also needs to be focused on old school quality.  Not the kind of quality that depends on a customer satisfaction survey.  The issues of diagnostic assessment and appropriate prescribing at at the top of the list.  How do we make sure that every person consulting with a psychiatrist gets a high quality evaluation and treatment plan and not a plan dictated by a managed care company?  The University of Wisconsin has a paradigm for networking with all physicians in their collaborative Memory Clinics program.  I see no reason why that could not be extended to different diagnostic groups across the state.  The focus would be on quality assessment and to prevent outliers in terms of treatment.  It could be open to any psychiatrist who wanted to join and it could have additional benefits of providing university resources like online access to the medical library to clinicians in the field.

An interested, excited, and technically competent psychiatrist is the ultimate goal of residency and it should continue throughout the career of a psychiatrist.  That can only happen with a focus on professionalism at all levels.  My definition of professionalism does not include managing costs so that  a managed care organization can make more money.  Psychiatrists need to forget about being cost effective and get back to defining and providing the best possible care.   

George Dawson, MD. DFAPA