Shirah Vollmer MD

The Musings of Dr. Vollmer

Pill Mills

Posted by Dr. Vollmer on July 12, 2013


Most employed psychiatrists are hired to prescribe medication to the many folks who are thought to suffer from mental illness, while another practitioner provides psychotherapy and/or case management. At first glance, this seems appropriate. The psychiatrist is the only one in the mental health food chain who can prescribe, and hence, maximizing psychiatrist time, means having them do the most prescriptions possible. On the other hand, this narrows and denies the scope of psychiatric training, and in particular, it denies the value of the psychiatrist-patient relationship. For example, Sally, a fictional psychiatrist patient of mine, works for a social service agency, where she spends thirty minutes with each patient, ten hours per week, prescribing medication, but she feels, and I agree, that those thirty minutes are cherished moments in these severely ill patients’ lives. In this time, there is a frank discussion of their psychosis, their internal struggles, and their present worries, along with a prescription refill. This time is valued by both the psychiatrist and the patient as the healing relationship. The prescription is, in some secret way, almost an excuse for the psychiatrist and the patient to get together. In point of fact, the prescription could be written by a nurse practitioner, or more refills could be given, but the need for the prescriptions allows for quality time together. Sally reminds me that because our health care system is devaluing the doctor-patient relationship, the ‘work-around’ is to say the visit is for medication, but in fact, to use the time to build rapport. In my wishful life, I would like psychiatrists, like Sally, to come out of the closet and say that we need time with patients because our relationship with them matters, whether we prescribe medication or not. We represent a professional who can listen, understand and care about their internal and external struggles. We can also supplement our listening skills with psychopharmacology. Both are important. It is time to go public with our healing relationship with patients. We offer this to those who have hit tough times in their lives. We, as psychiatrists, should be proud, and not ashamed, of our bonds with those who seek us out. We are not, and should not be, pill-mills!

2 Responses to “Pill Mills”

  1. Shelly said

    I definitely understand your feeling that you are not pill-mills, however in the US, one must bow to the almighty insurance company. Insurance does not cover a lot of hand-holding and understanding the inner struggles of its patients. They do, however, pay for pills. Lots and lots of pills. Even if you were to go head-to-head with the insurance companies and claim that you are preventing far greater costs down the road by preventing greater outbreaks of manic or schizophrenic episodes by more frequent therapy sessions, I don’t think insurance companies are as happy to fund the sessions as they are to medicate. Is this so?

    • The role of insurance companies, or third parties, in medical treatment, and in this case, psychopharmacology, is, as you suggest very complex. Most people, whether or not they can pay on their own, assume that they should use their insurance to pay for their medical care. Further, many people assume that their insurance company guides them to the right doctors and the right procedures, as they are not acutely aware that insurance companies have an agenda which may or may not coincide with the patient’s agenda. The question you raise is whether the patient, the provider or a hired advocate, should argue with the insurance company over the appropriate intervention. This, in my mind, is a very difficult issue. What is not a difficult issue, however, is that psychiatrists should not be “pill-mills” and if we could all agree, then insurance companies would have to pay attention.

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