Shirah Vollmer MD

The Musings of Dr. Vollmer

Psychiatry: Old Versus New

Posted by Dr. Vollmer on December 16, 2014

 

The old days, before my time, psychiatrists had few patients, relatively speaking, saw patients one or more times per week, and occasionally, very occasionally prescribed medication, which was usually a benzodiazepine for anxiety. These were the pre-Prozac days of psychiatry where most psychiatrists furthered their education with psychoanalytic training, and as such, were drawn to an in-depth exploration of the human psyche. 1988, Prozac appears on the scene, and suddenly psychiatrists are transformed into psychopharmacologists, seeing patients every fifteen to thirty minutes, maybe once a month, maybe once every three months.

Psychoanalytic training, meanwhile, was the purview of psychiatrists, until the  1980s when psychologists sued to be part of the club http://www.nytimes.com/1992/08/19/health/md-s-make-room-for-others-in-ranks-of-psychoanalysts.html. The perfect storm. Psychiatrists saw a niche in fast-paced, sporadic visits, pushing medication, and psychologists and  masters level clinicians could now enter, what was seen as,  the privileged class of psychoanalysts. The storm continues as Electronic Medical Records (EMR) enters the scene in the teens of our current 2000 decade. More clicks mean more “thought” and more “thought” means a better billing situation. With the caveat that EMR will help many millions of patients with their health care, specifically in terms of mental health, EMR furthers the distance between the doctor and the patient. Narrative history, the holy grail of psychoanalytic work, is minimized, and exchanged for checklists and binary questions. Discussions are relegated to “lower level professionals” as the jargon goes.

There are many perspectives here: the patient, the doctor and the population. The patient misses out on a clinician who both manages medication and does psychotherapy. The doctor misses out on having a family of patients who he deeply cares about. The population may be the rub, in that I can imagine that the good news with these changes is that more people will have access to a psychiatrist, however briefly, and maybe, just maybe, this will prove helpful to millions of sufferers. As I want to further this discussion, I recognize the potential benefit on population statistics, but what about the doctor who wants to really know his patients? Should he turn to another profession or, as some like to say, “go concierge”? What about the trainees caught in the transformation? Those, who entered the field before Prozac (myself, here), and yet graduated into a field post-Prozac. Or, those who entered medical training before EMR (2010 about), but graduate in a world of clicks and mouse. How are they supposed to cope? Adapt or die, or maybe rebel? For me, I am going to adapt, rebel and post.

 

See also…http://www.nytimes.com/2014/11/19/opinion/how-medical-care-is-being-corrupted.html?_r=0

7 Responses to “Psychiatry: Old Versus New”

  1. Shelly said

    Unfortunately, you will need to adapt to survive because your patients are mainly from the new world. Just guessing here, but very few are “old school,” prior to the world before Prozac and EMR. Now, if you are not computer savy, it’s seen as an anomaly. People may certainly enjoy the benefits of those long-term relationships with the psychiatrist, but patients really want quick fixes. They want to feel better NOW and don’t want to look into the reasons for feeling badly in depth. My vote is in adaptation and hopping on the bandwagon. I also foresee less and less medical students deciding to go into psychiatry when non-medical therapists can take over for everything except prescribing medication.

    • Prediction noted. Quick fixes, as you know, imply a simple problem, which, of course, most of us, do not have that simplicity in our lives. Embracing complexity, even though it is less desirable, in the long run, tends to pay off. If nothing else, we can begin to appreciate the enormity of our issues, if only to give ourselves comfort in knowing that our brains are complicated networks of memories and feelings, and even if we can’t “fix it” we can at least appreciate it. As for medical students going into psychiatry, I am not sure of the statistics, but given that I am involved with medical students who swing by LA to flirt with the idea of becoming a psychiatrist, there seems to be no shortage of takers. As to whether they understand the world that they will walk into in four years, well, that may be a different story. Thanks.

  2. Ashana M said

    All professions have seen enormous change in the last 50 years–from mechanics to teachers. I think psychiatry will need to adapt just like everyone else has. You can keep glancing backward, or you can look at the framework of what is to see what the opportunities are.

  3. Eleanor said

    From my experiences which, in the grand scheme of things, are limited, I don’t see deep thinking psychotherapy as something that is going to stay around to reach a decent segment of our population for any great length of time, unfortunately. I continually have to limit my opinions and use my words very carefully when mentioning anything that remotely reminds folks that our pasts inhabit our present and the importance of understanding these experiences and connections when need be. All this makes most people very uncomfortable…yes, fortunately some “get it , but not many. When help is needed, the term “counseling” (and short term) is popular. Psychodynamic approaches….forget them. (again, my experiences). Do these trends upset me…you bet they do….Todays lingo….”providers”, “clients”, “EMC”, etc. is the way our society is moving…..impersonal, mechanistic, and electronic.

    I would like to see massively funded programs in our schools…nursery through say…6th grade or so…screening children for early difficulties and then working with families from a psychodynamic prospective to help avoid major issues with the kids later on….easier said than done….

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