Thursday, November 15, 2007

Is This Psychiatry?

In her post Why Shrinks Don't Take Your Insurance Dinah talked about insurance reimbursement for psychiatrists and the effect of patient volume on revenue. She speculated that someone who ran purely a medication management practice could make a fair amount of money, but then she added this caveat: "I'm not sure I'd call it psychiatry, and I'm not sure how long I'd survive or how much better the patients would get, but hey."

I think I'm pretty qualified to answer those questions because I have the kind of practice Dinah is talking about. My clinical practice is entirely a medication management clinic within a prison. I have a high volume practice---two months ago I had the most patient contacts of any correctional psychiatrist in the state. I don't do high patient volumes for the money. I get paid the same hourly wage whether I see one patient in an hour or four. On the average, I see about three patients an hour. I see a large number of patients because there are a lot of people who need care and the majority of them have at least three risk factors for suicide. I see large numbers of patients for medication management because any one of them could die if I don't. And I don't do therapy sessions.

So is this psychiatry? Absolutely. I didn't become a psychiatrist because I wanted to be a therapist. I had no interest in psychotherapy and I honestly still don't. I became a psychiatrist because I enjoyed neuroanatomy and was really good at it and because I was fascinated by the functioning of the human brain. I wanted to be a 'real' doctor who treated people with serious brain diseases.

Do my patients get better? Some of them do, some of them don't, just like in private practice or any other branch of medicine. I can say that it's easier to tell if my medication management patients get better because I know what I'm treating and I have specific symptoms I can monitor. I think it's a little tougher to say that for psychotherapy; how do you know the therapy is working---because the patient says it helps and they say they like it? Because they keep coming back for more? Hard to tell.

Most psychiatrists practice in a range of settings, with a variety of patients, using a combination of therapeutic interventions. I don't have therapy sessions but I do provide crisis intervention and brief supportive counselling because sometimes the patient needs it right then, and you can't just cut them off and walk them into a counsellor's office. Psychiatrists in private practice usually have some patients who come only for medication management, and there are some patients who don't want psychotherapy. Some people might feel that advocating a med management-only practice exemplifies all that's wrong with the profession today, the death of the patient as an individual and the constriction of the profession. I counter that to cling to a private practice therapy model at the expense of public service med management is to abandon the most functionally impaired, at-risk patients whom only we are qualified to treat.