Shirah Vollmer MD

The Musings of Dr. Vollmer

The Embedded Psychiatrist

Posted by Dr. Vollmer on October 2, 2012

Oh, no. Psychiatry is heading towards another turn and once again, I am deeply concerned. As I understand the future of psychiatry, according to my highly respected colleagues, is that psychiatrists are now going to be “embedded” in primary care offices where they may or may not see the patient, but they will consult on the diagnosis and psychopharmacological intervention for patients that are seen by nurse practitioners and primary care physicians. Now, understand, that I work in primary care, and I am a strong advocate that primary care physicians should have psychiatrists to consult with on their cases, but this does not mean that the psychiatrist should not have the ability and skill set associated with deep listening to patients and understanding the nuances of a good evaluation. My concern is that the psychiatrists of tomorrow will help primary care physicians prescribe psychotropics, without developing the tools of listening to patients and having continuity with patients. Psychiatrists will mostly be trained to consult, without having direct patient care responsibilities. Once again, this will change the field, both in terms of how it is practice, and in terms of who is attracted to this kind of work. In essence, the doctor/patient relationship, the most valued aspect of the treatment, will disappear from the field of psychiatry. I have previously posted about the development of a psychiatrist, strictly as a psychopharmacologist, has minimized the doctor/patient relationship, but this new development, where the psychiatrist is strictly a consultant, takes my issue into a deeper concern. I wonder if history taking and relationship building will be a lost art in medicine. I certainly hope not.


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4 Responses to “The Embedded Psychiatrist”

  1. Jon said

    This is certainly a dystopic view of the future of psychiatry. Let us hope that your “highly respected colleagues” are portraying a future of psychiatry that will never come to pass. The noted speculative fiction author, David Brin calls the works of Ray Bradbury (Fahrenheit 451), George Orwell (1984), and Aldus Huxley (Brave New World) self-preventing prophesies. In this same, but less literary fashion, my your “highly respected colleagues” be auguring a similar non-existent future.

    • The issue here, Jon, not well articulated in this post (me-bad) is that the Affordable Care Act is promoting what they call a “Patient Centered Medical Home-PCMH” (see previous post with that title). In this PCMH, there exists a psychiatrist which is coaching the primary care physician about diagnosis and treatment. Although I think this can be very useful, if this is the only job the psychiatrist has, then he/she will not develop history taking skills which are critical to diagnosis and treatment. My highly esteemed colleagues understand that this shift in medical care is about to take place, and so chances are they are giving an accurate prediction of the future of my field. Stay tuned. Thanks.

  2. Shelly said

    Shirah, if this is not the only job the psychiatrist has, I don’t think the embedded psychiatrist is a bad thing. Currently, in the Middle East, primary care physicians prescribe antidepressants and psychotropics with very little psychiatric training. They shoot from the hip, as it were. If psychiatrists were consulted on a routine basis, I believe it would improve the standard of care and I think that more patients would be less hesitant to come to their physicians with mental health issues. The stigma would lessen. However, I can see that this would be frightening to psychiatrists as a whole: they would see their profession as becoming “subservient” to primary care, sort of like nurses or nurse practitioners.

    • I agree. The problem is that psychiatrists might be trained to be embedded and then this would be the only job he/she has, and this will be how he/she is trained to be a psychiatrist. Psychiatrists, in my opinion, can only consult to primary care if they ALSO have a private practice which gives them patient experience to draw upon. Psychiatrists who spend all of their time consulting, are also going to be “shooting from the hip” as you would say. It is not that Psychiatrists would be subservient to primary care, it is that they will not have the practice of history taking and without that, diagnosis and treatment decisions will suffer. Thanks.

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