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.