by Andrew F. Angelino, M.D.
[Winter 1996; Vol. 23 No. 4]
A funny thing happened on the way to work this morning - an insurance company decided what all the psychiatric residents were going to learn. It was a pretty subtle decision, so subtle that many of you may have missed it, but it dawned on me this morning as I sat reviewing my notes from the psychotherapy patient I had just finished seeing. He presented an old problem in psychiatry - the patient was showing up late for his hour. He complained of feeling low energy in the morning, but had no other depressive symptoms. I had a few ideas about the potential causes for this tardiness - resistance to therapy, early recurrence of major depression, bad traffic, etc. I am relatively confident that this is not a recurrence of major depression. The patient has been seeing me for several months, and I have already sent in one review to his insurance company requesting continuation of approval for psychotherapy. That time had come again. So just how does one request that payment be authorized for treatment of resistance to a discussion about interpersonal conflicts? This prompted a quick visit to my supervisor. It seems that lately, discussions about insurance are taking up about thirty percent of my supervision, intruding on time to discuss the dynamics underlying the presentation.
From that mildly disappointing scene, I moved to see one of my colleagues on an inpatient ward. She was in the midst of discharging a patient, and explaining to the psychotherapist that the patient had done quite well in the hospital once his medicines were restarted. Eager to find out if my friend was having a better day than I, I asked her if this patient had provided her a satisfying learning experience. She responded weakly in the affirmative, but, as we talked further, it became clear that her satisfaction derived from the patient’s improvement, not from any great educational advance. The patient had come into the hospital for a recurrence of symptoms as a result of stopping his medications. Once restarted, his symptoms gradually remitted. His cessation of medications was not addressed by the treatment team in any depth - there was no time to do so as he had only been authorized for four days in the hospital. Basically, as soon as his psychosis subsided, he had to leave. He is followed in a community setting for medication management once a month. Someone suggested a long-acting medication.
As a fourth year psychiatric resident, I have had the occasion to look back on my experiences with a fresh eye, and examine the educational process. Lately, I have wondered how my training has differed from that of my teachers. Speaking with a few of them, there are the usual reminiscences of the “good old days," when lengths of stay were longer and there was ample time to formulate and reformulate a problem, and of course, less paperwork and insurance review. Today, however, many find themselves resorting to “more efficient" medical models and “critical paths," all the while shifting the practice of outpatient psychotherapy into what more resembles a hundred-yard dash rather than walking a mile with the patient. But that is not even the whole problem. We cannot get all psychiatrists to agree that more efficiency is needed - that some patients actually do better in the hundred-yard dash than the marathon. One of my more vociferous professors even retorted that his immediate goal for the patient was the alleviation of symptoms, and his long-term goal the maintenance of that symptom-free state. He therefore concluded that he should be authorized to see the patient weekly for life. The patient’s insurance company reviewer begged to differ.
Moreover, a threatening trend has begun to arise. Even more basic than how psychiatry will be taught is the question of whether psychiatry will be taught. Managed care has claimed that there is a glut of psychotherapists. This has caused frightening statistics to come forth - one psychiatrist needed for every 200,000 population, It follows that managed care suggests that perhaps we do not need to train so many residents, and since training is expensive and has been identified as surplus, managed care is beginning to hint that the added costs of training residents should be paid by the training center, not by managed care. Maybe residents should be trained for free.
For now, however, let us assume (and this is a big assumption) that residents will still be trained in psychiatry. Three areas of resident education have been affected by managed care’s constraints on psychiatric practice: the length of inpatient stays, the numbers of outpatient psychotherapy sessions, and the supervision of non-physician psychotherapists.
First, managed care has decreased the length of stay of patients in the hospital. In my opinion this is a move forward - the days of 200-day stays are over. As doctors, our goals should include getting patients back to their “most functional" settings. The problem arises when hospital length of stay is so short that it limits what a resident learns about how to care for patients. True, there are many ways to learn, and repetition of basic principles is among them, but there are now patients whose paperwork requires more time than it takes for medication to take effect. The result is that residents are becoming efficient at working within a given set of parameters - doing a rapid evaluation, writing a “standard" set of orders, generating the required notes, and then, within the course of several days, arranging aftercare and discharge planning. The inpatient model is increasingly medical. This of course is wonderful, if the patient has a disease. Some, however, have disturbances of other sorts, such as abnormal behaviors and reactions to life circumstances, which may not respond to a week of hospitalization.
Two things are required to respond to this pressure. The first of these is the simplest - attending psychiatrists must return to the basics of diagnostics and formulation. Residents must be taught to present each case fully, with emphasis on observation of phenomenology, and then to formulate each case, with attention to the details that identify a particular patient as a member of a particular group. For example, “This young Caucasian lady has a family history of major depression, has very involved parents, upper middle class, and does exceptionally well in school. The cardinal features of her presentation include a profound fear of fatness and a cycle of starvation and exercise, during which she feels intense hunger, but after performing these certain ritual behaviors, this hunger seems to be temporarily alleviated. Her current weight is 74 pounds, but when observing herself in a full-length mirror, she identifies her buttocks and upper thighs as too fat."
My brief description of a patient with anorexia nervosa is the barest minimum that should be required of any resident before he or she can move on to making treatment decisions. My next point concerns “effective treatments." In order to get managed care companies to continue to pay for psychiatric services, there must be data to support that these services are effective. Teaching institutions are best-suited to produce good outcome data; they have motivated people who are interested in researching the examination, diagnosis and treatment of problems that arise in the mental life of patients. By teaching innovative examination techniques, current concepts in specific mental illnesses and state-of-the-art treatments, attending psychiatrists add value to the care rendered to patients. Residents learn the most effective treatments, which, when delivered well, become the most efficient treatments.
My second area of focus, shortening outpatient psychotherapy, differs from shortening inpatient length of stay in several ways. Again, there is a concern as to whether residents will eventually be taught psychotherapy at all, since non-physician psychotherapists tend to charge less and thus get the larger share of managed care patients, Nonetheless, the issue in decreasing the number of visits for which a patient is “approved" has influence on the psychotherapy itself, which is difficult for a novice therapist. The effect of putting a time constraint on the therapy practiced by a resident can be devastating. Residents are becoming adept at short-term, supportive psychotherapy because that is what they are given the opportunity to practice, but they remain ignorant of or impotent to the subtleties of the psychotherapeutic hour that often arise only after the first six months.
The final area of resident education that I wish to discuss is particularly problematic. Due to the pressures of managed care, psychiatrists are now increasingly reliant on so-called “physician extenders;" a good amount of clinical practice today involves psychiatrists providing medical back-up for and supervision of psychotherapy for non-physician therapists. This concept is implicit in the “one psychiatrist per 200,000 population" idea. Just how does one teach a resident to supervise the therapy of someone who has been doing therapy with a particular patient for two years longer than the resident has been a doctor? He or she probably does not have the faintest idea of what it must be like to direct the care of a patient without delivering it. The old medical student’s adage of “See one, do one, teach one" becomes especially poignant here.
To this quandary, I must again reply that clarity is the key. The resident who will learn to supervise well is the one that is supervised well, with focus on clarity of formulation and treatment process and goals. Residents need to practice supervision of therapists in a supervised setting, perhaps even with the use of videotaped sessions or one-way mirrors as are used for the supervision of resident therapy. I am not in favor of an endless march of supervisors, each attentive only to the issues of the supervisor-supervisee interaction. The focus should be on the effective supervision and medical back-up of the therapist’s care, attending only to those therapist-specific problems that arise.
In summary, managed care has lit a fire under the practice of psychiatry, to burn off the inefficient delivery of care to patients. The effect of this has been, in many areas, to increase activity and decrease focus, and we are left with commotion and chaos. Patient lengths of stay are now shorter than ever, the number of outpatient visits is decreased, and increased numbers of non-physician providers are performing psychotherapy each day. In the area of resident training, however, attention to careful diagnostic evaluation and a methodologic approach to treatment, with demonstrable goals and outcomes, will ensure continued delivery of expert psychiatric education despite these pressures of managed care.