Shirah Vollmer MD

The Musings of Dr. Vollmer

The Loss of Intellectual Capital

Posted by Dr. Vollmer on September 16, 2013

I have this conversation multiple times a day. “What jobs are out there for psychiatrists?” a student asks. “Psychopharmacology jobs,” I respond with a sense of horror and shame. Agencies dealing with the mentally ill, look to the psychiatrist for a prescription, and not for an assessment or treatment plan. This means that when psychiatrists look for employment, their jobs are to write prescriptions, with different employers having different expectations for how much time to spend with a patient in order to write this prescription. Adding on, agencies are also asking psychiatrists to trust the assessments done by other professionals, rather than taking the time to make their own opinion. This is my rant, a major incentive for my blog. How can this be? How can organizations not appreciate that we, as psychiatrists, bring so much more to the table than our prescription pad? We bring an understanding of the brain, the mind, and the body. We have lost our way, and now we need to get it back. We need to remind the public that our assessment skills are valuable and they take time, which will be well spent in developing treatment plans for patients. I will repeat this theme over and over again, as it stands now, psychiatry has to right itself. We are like an insect on our backs, flailing our legs to turn over so that we can  stand up and move on. I hope we turn over soon.

10 Responses to “The Loss of Intellectual Capital”

  1. Jon said

    Yes, you have ranted and many of us, your commentators, have agreed that a psychiatrist is much more than a provider of psychopharmacology. Diagnoses are best made by a psychiatrist. Treatment, be it biochemical or giving the mind thoughts to chew upon (or both), are also best provided by a psychiatrist.

    So, some questions…. How can one raise the consciousness of the powers-that-be that there is more than dispensing drugs? This blog is good, but is it preaching to the converted? Who are the powers-that-be and what can motivate them? Is it strictly financial? Can a long term cost/benefit analysis be shown to be more cost effective?

    • Thanks, Jon. Yes, my rant is repetitive, with the hopes that people such as yourself will help me learn to make it a spiral and not a circle, so thanks again.

      Yes, I am preaching to the converted, and that, as you suggest, is a problem.

      I do think that the financial piece is large. Resources are divided up, such that everyone maximizes their license, which is code for “since no one else can prescribe meds, have the psychiatrist do that, since other professionals can do the assessments for a lot less money.”

      We clearly need a long-term cost/benefit analysis to guide us towards a change in health care policy. You remind me of my previous passion to be involved in such research.

      You give me a lot to think about.

  2. Ellen said

    My take is, if you want to do actual therapy with clients / patients, don’t go into psychiatry. Sure, MSWs, psychologists and other therapists make less money and have less status than psychiatrists. But they are the ones who work with people. That’s only my experience of course.

    It does seem to me that since psychiatry wants to be a ‘real science’, biologically based, then it does follow that psychiatrists contribute to mental health with pills and other physical interventions, much like other doctors do. Whether they need a long time to figure out what to prescribe, or a shorter time, seems like a bit of a side issue as to what their role is.

    It’s obviously a complicated issue. My two cents.

    • Thanks, Ellen. I appreciate your “two cents.” I think the complication is that one wants many tools to help patients, and so the MD degree adds to the tool box. It is nice for doctor and patient alike, to go to one place for both therapy and medication. Medication in the context of psychotherapy serves to provide a comprehensive treatment plan, and so without the ability to prescribe, in some situations, the treatment is more limited. Thanks again for chiming in.

      • Ellen said

        I can see how theoretically this could be helpful. But wasn’t your whole post about the fact that this is not happening, that psychiatrists are only prescribing? Which is likely a result of what insurance companies are willing to cover. Therapy gets expensive. I may be cynical, but I’ve found that’s the bottom line.

        Sorry to be negative. My own experience with psychiatry was not positive, but I enjoy your blog and point of view.

        • Hi Ellen,
          Yes, my whole point is that in terms of employment, there are no employers, that I am aware of, that will pay a psychiatrist to do psychotherapy. Further, few psychiatrists are in leadership positions in mental health agencies. This applies to both child and adolescent psychiatrists, as well as adult psychiatrists. Your cynicism matches my experience. Having said that, as a self-employed psychiatrist, I am able to do psychotherapy with or without psychopharmacology. I am interested to hear about your experience with psychiatry, if, of course, you are comfortable sharing. Thanks for reading my blog and commenting.

  3. Shelly said

    Where I live, my loved ones are often shuffled between neurologists and psychiatrists as the medical systems doesn’t quite know how to handle my family’s problems. Perhaps if psychiatrists work hand-in-hand with other medical physicians then “your employers” will foot the bill for therapy? I know it is painful to hear that psychiatry needs to take “a ride” on the back of another medical specialty, but the bottom line is always economics: medical insurance will pay for neurological procedures and appointments but not for psychiatric ones. I don’t know if this has to do with the stigma issue or not. Perhaps psychiatry needs its own lobby in the AMA.

    • Yes, your model of healthcare is being imported into the United States. We are also starting to embed psychiatrists into primary care. I do not think it is painful to ride on another specialty, but I do think that other specialties look to us for prescriptions and not assessments and treatment planning. I think it may have to do with stigma, but it also relates to the issue that our outcome studies are very primitive and hence we cannot scientifically justify what we do. Having said that, insurance does pay for drug rehabilitation programs which also cannot document efficacy. I work in a field of tremendous uncertainty and in the age of wanting an algorithm, there is no room for grey. Thanks.

  4. Ashana M said

    The problem is that psychiatrists now have too much expertise to do much else. Many aspects of the mind can be treated without any knowledge of pharmacology because many treatments for the mind involve none. Someone with less knowledge can be trusted to do psychotherapy and even diagnostic testing. And my general practitioner could also prescribe medication for some kinds of simple problems–like depression or anxiety. In practical terms, what this means is that a fairly narrow set of needs specifically require the services of a psychiatrist, and because of cost issues, those are the only needs someone is likely to see a psychiatrist for. Anything that can be done by someone else will most likely be done by someone else. Knowledge is an expensive commodity, and resources are finite. If psychiatrists were to radically reduce their fees–and essentially give away that additional knowledge for free–then they could offer a broader range of services, but what they have done instead is priced themselves out of the market for those services. It’s a completely fixable problem, but I don’t think anyone is motivated to fix it.

    • I am not sure that psychiatrists have priced themselves out, or that the supply and demand has been such that there was a market for psychopharmacologists, allowing many psychiatrists to narrow their focus in a way, which to me, seems detrimental to the field. Thanks.

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