Ask For Updates, Write Prescriptions, Ask to See Next Patient: Is This Psychiatry Today?
The practice of psychiatry has become more and more about limited (15 minute) consultations with patients with the principle aim of consulting about psychiatric medications and refilling prescriptions, a far cry from the image of earlier days when patients, stretched out on couches, elaborated about their anxieties to bewhiskered doctors seated in leather armchairs. One reason behind the change, according to the New York Times, is insurance companies, which reimburse 45-minute talk therapy sessions at a lower rate than the 15-minute ones to refill prescriptions.
A psychiatrist can earn $150 for three 15-minute medication visits but only $90 for a 45-minute talk therapy session. Psychologists and social workers (who don’t attend medical school and ‘can often afford to charge less’) can also provide talk therapy. There’s no evidence that talk therapy provided by psychiatrists is of better quality.
The New York Times article profiles a psychiatrist, Dr. Donald Levin, who runs a private practice in Doylestown, Pennsylvania. Dr. Levin works 11 hour days and sees 40 patients a day. Initial consultations are for 45 minutes, with the following visits lasting for 15 minutes. Dr. Levin’s wife runs the business side of his practice with a set fee schedule for patients: $50 for a missed appointment, $25 for a faxed prescription refill and $10 extra for a missed co-payment. In those short sessions,
Dr. Levin asks for quick updates on sleep, mood, energy, concentration, appetite, irritability and problems like sexual dysfunction that can result from psychotropic medications.
“And people want to tell me about what’s going on in their lives as far as stress,” Dr. Levin said, “and I’m forced to keep saying: ‘I’m not your therapist. I’m not here to help you figure out how to get along with your boss, what you do that’s self-defeating, and what alternative choices you have.’ ”
As the doctor himself emphasizes, he was not at all planning to perform such rather assembly-line like care:
Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.
Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.
Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. “I had to train myself not to get too interested in their problems,” he said, “and not to get sidetracked trying to be a semi-therapist.”
While Dr. Levin could have decided to accept less money and still provide ‘time to patients even when insurers did not pay,’ he notes that he preferred not to, for financial reasons. The average salary for a psychiatrist in 2009 was $191,000, the says. As the New York Times notes, ‘to maintain their incomes, physicians often respond to fee cuts by increasing the volume of services they provide, but psychiatrists rarely earn enough to compensate for their additional training.’
Interestingly, even though Dr. Levin describes himself as more of ‘”a good Volkswagen mechanic,”‘ six of his patients interviewed by the New York Times say they like him and note they indeed feel better even though ‘recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression.’
The changes that Dr. Levin has experienced in his profession strike me as emblematic of how health care and the medical professions have evolved in an age when it so often seems that insurance companies are the ones who call the shots about what kind of care we get. While I’ve personally seen how psychiatric medications can help some, it does seem regrettable that more and more (except the very wealthy who can afford to pay $600 in cash per session to a psychiatrist) are relying on medication—on little light blue and orange pills—to manage our stresses, anxieties, depression, and more. Have we turned psychiatric care into a just another business, more concerned about efficiency and the bottom line than the care of those who suffer?
Photo by SwedishCarina.