Psychiatry Has Become Neurology: Now What?
Posted by Dr. Vollmer on March 9, 2016
Most psychiatrists see patients for brief time slots and with long intervals between appointments. This is the Neurology model of care. Diagnoses are made, followed by brief visits every few months. Neurologists can use imaging studies to be more precise with their diagnoses, but Psychiatrists are hoping that will be true for them one day as well. In the meantime, the identity of a modern day psychiatrist is one who sees a large number of patients per day, and beyond that is responsible for a large patient load, as patients are not seen very often. Consequently, the particulars of the individual are not attended to, and continuity of care is thin, at best. Who then, pays attention to the details of everyday life; the stressors which trigger feelings of sadness, anxiety and psychic pain? Is this the job of the non-MD psychotherapist? Perhaps, but how does medication get administered when the physician only knows the current symptoms, without historical context? Maybe the non-MD therapist has good communication with the physician, such that a more informed medication program can be conceptualized? How though, does this physician keep up with all of the different therapists that his patients are seeing? Let’s do the math. A patient every 15 minutes means 4 patients per hour and 32 patients per 8 hour day and 160 patients per week, and about 640 patients per month. Of course, there are new patients thrown in there, which will let’s say be one hour appointments, but still the numbers grow quickly. My issues are two-fold. How do patients get good care with this model and how does the physician feel job satisfaction if he does not know the people he is treating?
A fictional tale comes to mind. Arden, twenty-seven, alcoholic, unemployed, recently broken up with her boyfriend, reports with little affect, “the reason I feel so terrible right now is that the doctors have not been able to find the right medications to help me.” My viscera begin to speak to me. Wow, I think to myself. My profession has really done it again in that Arden is now believing that the problem she has is not related to her alcoholism, her unemployment, or her recent break-up, but rather it is the doctor’s fault for not finding the “right” medication, as if she has a terrible cancer, and there is just no chemotherapy to help her. The psychiatric profession, by being so focused on psychotropic drugs, has encouraged Arden to believe that her mental state can be fixed by medication, and her problem is that she just has not found the right doctor yet. The shift of responsibility from personal growth to dependency astounds me. The belief that medications can change mental suffering and overcome life’s difficulties is a poor message for patients like Arden. She needs to understand that she has to figure out her pain such that she can grow and make a good life for herself, and in so doing, she will feel better. Psychotropic medications may offer some assistance but they are not “the answer” to her problems. As her fictional psychiatrist I can help her see this, but the advocacy of psychotropic medications is so strong she will likely seek another doctor. Once again, I want to say, Psychiatry has lost its way and that is a double loss for both the patient and the physician.