by Bruce Hershfield, MD
[Fall 1997; Vol.24 No. 3]
I don’t know if psychiatry will unravel and disappear, but I think I know how it will happen if it does. First, patients need to get the idea that they are best served (or, at least, cheapest served) when their care is split between a nonpsychiatric therapist and a “med-check” psychiatrist. Then, if they don’t get to see a therapist, they still get only a few minutes of the psychiatrist’s time because that’s all the plan permits. Finally, their med checks are switched to a family physician, which saves money for the “managed care” company that has pretended to serve the “psychiatric needs” of the population.
This is, to speak plainly, a fraud. But why are so many psychiatrists willing to provide med checks?
The argument is made that splitting the care lowers the costs because nonpsychiatric mental health practitioners generally charge less per hour than psychiatrists. I believe, however, that patients stay longer in therapy when their care is split. It’s easy to see why. Many “therapists” explore lots of material from the past in the hope that patients will stop being symptomatic if they just talk enough about the trauma they’ve suffered. At the same time, the psychiatrist may be telling the patient to distract himself to stop an obsession, to focus on anything but the origin of the fear if she’s having a panic attack, or to accept that some events can’t be changed.
When are the two “providers” going to communicate about their strategies, changing them frequently as the “consumer” changes?
Never. Well, hardly ever, unless they want to do it during time when they’re not being paid, because treatment, a good note, and a documented communication between the providers, all in a 15- or 20-minute med check, are unlikely. I’m not even talking about unpleasant circumstances, such as when the providers don’t know each other, or are hard to reach, or just don’t agree on what they’re trying to accomplish.
And there are more dangers. More than 15 or 20 minutes will be needed if the patient has a complicated problem. If it can be resolved in a few minutes, why involve a psychiatrist? (The patient probably should be seeing a family physician.)
Whom should the patient call in a crisis? What will be the psychiatrist’s legal liability if there’s an “adverse event”? And if there is, how likely is a suit if the patient barely knows the psychiatrist and if the psychiatrist is seeing four or more patients per hour and has a caseload of 200 or more? Whom do you think the patient or family will sue?
I have a simple solution. I won’t do med checks, and I won’t work for companies that violate the APA policy that says they should provide a full array of psychiatric services.
There have always been forces attacking and cheapening psychiatry, but I think we should not cooperate with them. The short-term “gains” of being seen as “cooperative” by “case managers” are outweighed by the many dangers to patients and to the integrative concept of psychiatry. That concept is especially important in Maryland, where the biopsychosocial model of psychiatry has been used to help patients for generations.
When a secretary for a managed care company recently asked me if I’d provide med checks, I asked in return, “Would you see a psychiatrist for 10 minutes?”
“No,” she laughed, “I wouldn’t.”
“So how can I ask my patients to?” I asked.
“Others do,” she told me.
“Well,” I said, “I’ve heard that ‘others’ also commit suicide sometimes, but I’ve never felt inclined to join them.”
And you shouldn’t, either.