Shirah Vollmer MD

The Musings of Dr. Vollmer

How Many Patients Should Residents See? The Confusion Of Medical Training

Posted by Dr. Vollmer on May 3, 2012

When I was in training, I had six or seven outpatients, three clinical supervisors, along with the responsibility of doing inpatient psychiatry work. In this pre-Prozac era, there were not very many “outpatient clinics” since there was very little that we could do for patients on an outpatient basis, other than psychotherapy. Today’s resident spends his time in a series of clinics in which he prescribes medication to patients in a medical model which resembles a primary care visit. In programs that I am familiar with, the requirement to do long-term psychotherapy work is usually one or two cases a year, during his last two years of training. Once again, I must ask myself if I am resistant to change or if this change is harmful to our future generation of psychiatrists. The training programs are focused on the brain and not the mind. Hence, the medical student drawn to psychiatry is a different student than in my day when the common thread in going into psychiatry was the passion to mine the mind. The sadness I feel about this cannot be overstated. I am not saying that every psychiatrist trained today does not appreciate the depth of meaning which is learned from deep listening. However, I am saying that the priorities have shifted such that a “clinic” model of psychiatry is overtaking the long-term psychotherapy model of psychiatry. This shift causes most psychiatry residents to feel most comfortable with a prescription pad and less comfortable with formulating psychodynamic understandings of how a patient’s mind has come to give that patient deep suffering. I am left to hope the pendulum will swing back to prioritizing intense listening. This skill is what so many patients need to heal. Have I said this loudly or too many times? I don’t think that is possible. This series of posts will continue until training programs turn back the clock, just a little, in order to bring back psychotherapy training. Change is good, sometimes. This change was too far.

5 Responses to “How Many Patients Should Residents See? The Confusion Of Medical Training”

  1. Shelly said

    Excellent post, Shirah. I’ve been away from the US too long to know if psychiatry is still covered by insurance, and if it is, does it cover more than a 20-minute medical management session? Where I live, there are so few psychiatrists that demand far exceeds supply and the wait for appointments can be months long. When one finally gets an appointment, there is no intake, just 5 minutes to explain the problem before the MD writes a prescription and you’re out the door. I am sure that if you had patients who wanted to pay out-of-pocket for long-term therapy (like we do in our country) intense listening skills would be prized over prescription-writing ones. Your residents need to learn both skills. At least, that is my opinion.

    • Thank you, Shelly. Psychiatry is covered by insurance and each insurance plan is so different, such that there are a multitude of coverage issues with regards to psychiatry. The idea, as you suggest, is that if residencies are teaching psychiatrists to do what insurance companies want them to do, then there is something very upside down about that. Educational institutions should dictate what psychiatrists need to learn, not insurance companies. We know this, but it is hard to implement that. Thanks Again.

  2. […] individual experiences of… you know.. real life. Therefore it was nice to see shrink blogger Shirah Vollmer’s much more personal take on this trend. (Also a really interesting and very active blogger to add to your RSS feeds). It does seem to me […]

  3. Danny said

    HI Dr Vollmer,
    Couldnt agree more with your post. thaks for your informative blog as always.

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