Are We Training Psychiatrists to Provide Only Medication Management?

In reviewing the practice patterns of psychiatrists today, it is clear that many provide mostly medication checks or medication management for their patients. The conventional wisdom for this model of practice is that it is based on current methods of payment for clinical service, which places a premium on brief interventions by psychiatrists. Medications must be prescribed by a physician, while a non-MD mental health worker can provide psychotherapy and be paid by an insurance company at a lower unit cost than that paid to a psychiatrist to perform the same form of treatment.

Although it is true that today’s economics encourage the practice of medication management by psychiatrists, the current structure of clinical experiences in residency training programs may also serve to implicitly encourage and support this model of practice.

The practice of psychiatry is the merger of scientific disciplines that inform us in understanding behavior and caring for our patients. The science of psychiatry is taught effectively in most, if not all, psychiatric residencies by a graded curriculum that addresses the biology, psychology, and social factors of human behavior. Resident performance on the psychiatric resident training examinations (PRITE) taken during each year of residency and the written examination of the American Board of Psychiatry and Neurology for certification confirm that current graduates are well versed in the varied aspects of the science of psychiatry.

The art of psychiatric practice is learned by residents during various supervised clinical rotations. Each rotation has a number of stated learning objectives and related competencies that a resident must master. But once the resident masters the required competencies, is he or she in fact able to perform these required competencies? The ability to perform in a clinical rotation may not mean that the resident has the competence to practice unsupervised. In assessing performance during or after a rotation, we must determine whether the resident will be able to practice in the field.

While one learns science in an academic framework, the art of psychiatry is learned experientially, in graded supervised settings. The skill set grows with increased experience. In psychiatry more than any other medical specialty, the art of being a psychiatrist is most critical. The psychiatrist’s core knowledge, skills of interviewing, and his or her empathic capacity serve as the diagnostic imaging and laboratory tests of other medical specialties.

The only activity that the psychiatric resident is able to master . . . is . . . prescribing medication . . .

The psychiatrist performs a diagnostic assessment by talking to the patient and to individuals in the patient’s life. After completing the diagnostic interview, the psychiatrist may obtain information from other professionals and from laboratory results. A unique form of information for psychiatrists regarding their patients, which is frequently not acknowledged in both the diagnostic and therapeutic process, is the psychiatrist’s empathic sense of the patient. Using all the collected data, the psychiatrist makes a DSM diagnosis and answers any special concerns regarding the patient. At this point, a treatment plan is developed. Assessing patients and developing and instituting a treatment plan is the essence of the psychiatric residency.

Once the psychiatric resident completes the primary care and neurology rotations, he will start to work on psychiatry inpatient units. Typically, the resident works with an attending psychiatrist and sees 7 or 8 patients daily. Attending psychiatrists must see the patient and play a key role in the patient’s treatment or they cannot bill for their services. This is a change from 20 to 40 years ago, when the resident was the only doctor to see the patient.

Today, the resident and the attending psychiatrist make a joint diagnosis and work with other members of the team, such as a nurse and a social worker, to develop a treatment plan. Frequently, the only role for the resident is for the medication treatment of the patient. The resident may participate in family interventions, but work with the patient’s family is usually left to the social worker. Because of the rapid turnover of inpatients (5 to 7 days on average), psychotherapy is usually not an important part of the treatment. Stabilization with medications and group therapy are the core of the treatment. In the course of his rotation, the resident may see more than 300 patients. Once a patient is discharged, the resident is often unable to follow up with him and does not know the outcome of the treatment unless a patient is readmitted.

At the end of the rotation, the resident can perform diagnostic assessments, work with others to develop a treatment plan, and direct the medication management of a patient. The resident may not, however, be knowledgeable about the extended impact of the medication on the patient.

The resident may then move on to a psychosomatic medicine rotation for 2 months, consulting on patients in medical or surgical units. The resident’s primary responsibility is to make a quick diagnosis and propose a rapid intervention in conjunction with the medical or surgical team and nursing staff. During the supervised consultations, the resident participates in a psychiatric subspecialty, where he may be more of an observer than an active participant. Once again, because of today’s short duration of hospital stays, the resident has limited knowledge of the outcome of his treatment interventions.

On child psychiatry rotations, the resident’s active role in working with children may be limited. The resident functions primarily as an observer. Clinical work is usually heavily supervised and observed. A similar experience may occur on a 2-month rotation in geriatric psychiatry.

In most residencies, outpatient work is a minimum of 12 months in the resident’s third year. The resident is given diverse supervised responsibilities and is required to develop abilities in a number of psychotherapies, including dynamic psychotherapy. Residents generally have between 3 and 5 dynamic psychotherapy cases at a time. If we assume each patient is in treatment an average of 4 months, the resident could have between 12 and 15 patients in psychotherapy during the course of the year. Many of these patients would also be taking medication, and a significant number of other patients would be seen only for medications.

Residents can quickly demonstrate in formats constructed by their teachers that they can perform a number of tasks. However, on their own-outside of their residencies-their skills may be limited. One masters an art by the repetition and learning about oneself and one’s abilities. Unfortunately, in many residency programs, the only activity that the psychiatric resident is able to master in this fashion is in prescribing medication. Experience with a handful of patients in dynamic psychotherapy may not be adequate for the resident to feel that he has mastered psychotherapeutic skills. It is not surprising that on graduation, many residents pursue a career in which their main role is medication management.

Many of today’s residencies reinforce mastering only the art of applying knowledge of the biology of behavior, which informs the use of medications. The unanswered question is, can modern clinical psychiatry survive if training programs provide clinical experiences that may produce expertise in only one of psychiatry’s core disciplines?

Residents must be given adequate time during their training to learn and incorporate the psychological and social elements critical to being a psychiatrist. If psychiatry reduces or abandons its engagement with psychology and social science in understanding and treating mental disorders and focuses predominantly on the biological factors of mental disorders, what will our role as psychiatrists be? Other physicians may assume the responsibility for medicating patients with mental disorders, and others may take on the role of integrating the biological, psychological, and social forces that have an impact on behavior.