Private Practice Changes: A Personal Perspective

I hear and read often about how unhappy my colleagues are with the changes in medicine that have resulted, over the past 20 years, in the loss of autonomy and increased the burden of paperwork in daily practice. Almost four years ago, after 31 years of private practice in the same office, I had to relocate because of construction. The process of moving two blocks was traumatic, but as a coping mechanism, I began to review old charts and records. I found myself musing over long-forgotten patients and wondering what happened to them. It was amazing how much my practice had changed over the years, in many ways so slowly and subtly that it was difficult to appreciate along the way. Despite all the changes, both for better and for worse, I am enjoying my practice as much today as I ever did before.

First, let me describe my background. I completed my internship and residency training at Mt. Zion Hospital in San Francisco (1962 to 1966). The training program had a strong analytic emphasis. Senior faculty from the San Francisco Psychoanalytic Institute provided most of our courses and supervision. Our training was essentially outpatient psychotherapy, which consisted of 20 hours a week of one-on-one, long-term, intense therapy (one to three times a week). There was little or no instruction in crisis intervention, consultation, time-limited therapy, substance abuse, AIDS or many of the other issues that we face today in psychiatry. Medications were just starting to be used for outpatient treatment, but were seen more as a temporary bandage. For the next 10 years, I practiced essentially what I had been taught. In the mid-1970s, I began to broaden my theoretical horizons. Since that time, I have tried to tailor the use of different treatment modalities such as psychopharmacology, in-depth dynamic therapy, cognitive therapy or behavioral therapy, as well as duration of treatment (such as long- or short-term therapy) to each patient's needs. In addition, I have kept my practice doors open to a variety of patient populations and see myself as a general psychiatrist.

The diversity I have always enjoyed in my practice extends beyond treatment options and patient populations; it extends to how I spend my professional time. A typical week consists of 30 to 35 patient hours, five to 10 hours working with patients living in residential care facilities, and two to three hours teaching, as well as a few hours a month involved with organized psychiatry and actively involved with family and patients' advocacy groups. This variety has enabled me to see many sides of psychiatry and keeps me stimulated.

After 30-plus years in practice, my perspective includes the following:

Psychiatrists, being the most broadly trained mental health clinicians, should treat the most disturbed patients.

Patient screening should be kept to a minimum. If a clinician refers a patient to me, I will generally accept the referral and then let them explain why they think the person needs to see a psychiatrist. With cold calls directly from patients, I do more screening; however, these are often the most interesting and rewarding cases.

The debate between short- versus long-term treatment, I believe, sets up a false dichotomy. The crucial issue centers on the intensity or frequency of treatment rather than solely on the duration of treatment. The debate should set up the dichotomy of intense (weekly or more sessions during psychotic episodes or crisis) versus non-intense (bimonthly, monthly or episodic visits that can last for years).

Managed care has brought some positives along with the well-publicized negatives. I worked for 20 years in the fee-for-service environment and loved the freedom, the non-intrusiveness by outside parties, not having to create treatment plans, easy billing and so on. I certainly do not agree with the bottom line justifying the denial of treatment or CEOs receiving large salaries. But fee-for-service also had its abuses, such as hospital stays being extended until the insurance ran out, the rapid spread of for-profit hospitals and, without oversight, the healthiest patients often received intense long-term treatment at the expense of patients with more severe disorders.

With the rise of managed care, we have seen fewer for-profit hospitals, the scaling back of inappropriately long hospitalizations and lower co-payments that have brought employees with lower incomes to psychiatrists at earlier stages of illness. Hopefully, the worst abuses of managed care are being dealt with, and the pendulum is slowly swinging back toward physicians and patients.

Comparing my practice in 1978 with 1998 and working approximately the same number of hours per week, I still found many differences (Figures).

The number of patients that I saw nearly tripled. This was mainly due to seeing patients less intensely and not seeing them for a shorter term. The number of referrals increased. Referral sources went from mostly physicians and other mental health care professionals to managed care companies now making many referrals. The patient gender ratio went from more female to more male. The number of sessions per patient per year reduced greatly. Surprisingly, the length of treatment had not changed that much, the major change was intensity. Diagnoses remained relatively the same, but the major change was the number of patients on medication for depression, anxiety and substance abuse. The age of my patients also increased. I believe this increase may reflect my own aging.

There are many factors that have contributed to the change in my practice patterns. As I get older and see how scientific knowledge has altered our view of the brain and mind during my career, I have become less dogmatic regarding what is best for the patient. I usually present the various options -- dynamic, cognitive, behavior and psychopharmacology -- and try to build more of a partnership in developing a treatment plan that fits the patient's needs, finances and time. Gone are the days of "Doctor knows best." I use more of an educational approach, including encouraging patients to read and use the Internet to learn about their disorders and medications. People are very busy these days and after getting to know the patient, I find they are often relieved that they do not have to come in so frequently. With less intense treatment, I find the use of the telephone increasingly important. My office number goes into my home on evenings and weekends, and there is very little abuse. I am not getting any more calls now than in the past, and I attribute it to patients being less dependent and more self-reliant.

With more patients in my caseload and seeing them less intensely, it is agreeable to take a few notes during the session with most patients actually seeming to appreciate it. Only the most paranoid patients ask how the notes will be used or decline. The reduced stigma of mental illness and managed care are two reasons, I believe, patients of lower socioeconomic status and males are more willing to see a psychiatrist. Improved medications and direct-to-consumer advertising -- good and bad -- of psychotropic medications result in patients being more open to the use of medications and using them more frequently.

In the '70s without managed care, I did my own billing. Today, private practice psychiatrists need support in running their practice, particularly in regard to billing. Over the years, I have had to make great changes in how I practice, some good and some not so good, i.e., paperwork and intrusion into the doctor-patient relationship. The good is the diversity of patients and that patients in general are less dependent and usually willing to take more responsibility for improving their own mental health. I feel my understanding of the brain and mind is better today than it had previously been. We now have better medications that are safer and have fewer side effects. I do not have to be as passive in the therapeutic session as when I first started my practice. Being more active in my interpretations and more of an educator as a therapist is rewarding. By seeing more patients and probably more disturbed ones, I am more relevant to society. Yes, despite and because of the many changes, I am enjoying the private practice of psychiatry as much today as I did 20 years ago.

One might ask why I am still enjoying practice with all the negative feelings that we hear toward the managed care industry. One has to look at the history of why managed care was instituted 10 years ago. Medical costs were going up twice the inflation rate and, unless something was done, we were most likely headed for a single-payer system, which certainly most clinicians did not want. Managed care was instituted rather suddenly with an attitude of "Take it or leave it" and with little input from practicing clinicians. This was perceived as arrogant and soon became very intrusive in the doctor-patient relationship, greatly increasing burdensome paperwork and lowering reimbursement rates. Over the years, managed care companies had to change or they would have had few psychiatrists remaining on their panels. In general, managed care companies today are less intrusive, are reducing paperwork and are raising reimbursement rates, and as they make these changes, it is easier for psychiatrists to work with them. Psychiatrists have also changed their practice patterns over the years, which I believe has very little to do with managed care. These changes are the results of a reduced stigma of mental illness, patients coming in earlier and patients being more compliant with treatment. We are having better treatment outcomes including better medications, which encourage patients to seek treatment. Successful research into our understanding of mental illness makes treatment more effective. We hospitalize less often and for shorter stays because we think it is better for the patient.

We tend to see patients less intensely because patients are busy and we have found for most patients you have good results. As my records show, I do not see patients today for briefer treatments than when I began my practice. The big difference is that I see them less intensely. As managed care companies understand these changes in practice patterns and realize they do not need to micromanage, hopefully there can be more trust and dialogue between clinicians and payers and less confrontation and anger.