Psychiatry: Awaken and Return to the Path

The recentNew York Timesarticle by Harris³ presented some of the current challenges facing psychiatry, but did so amidst a distorted backdrop, and to the melody of a phantom Greek chorus. I leave it to my colleagues to filter out the distortions according to their specialty and predilections. Instead of focusing on the more astonishing inaccuracies, such as there not being much to “master” in psychopharmacology, I should like to address a few subjects that may have the potential to create a more insidious and enduring form of misrepresentation ... namely, the implications that psychiatrists must now “play the game,” and resign themselves to a bleak future of harried pill dispensing. 

I’ll not soft peddle our dilemma. I do think a strong argument can be made that psychiatry is, in part, responsible for the circumstances in which it currently finds itself. In the recent past, psychiatric research has suffered humiliating dishonor in terms of allegations of fraud and selective publication of clinical trials.⁴ And now, some psychiatrists may find themselves terribly discouraged by the current state of the psychiatric union. In particular, they are saddened by the “business” of medicine, how it no longer pays as well, and how it has curtailed their very ability to listen to patients. My initial reaction to the article was predictable: How sad. This is terrible. The psychiatric sky is falling. Yet after thinking about the big picture, speaking with psychiatric colleagues and re-reading my prized copy of Aequanimitas, it occurred to me – this New York Times article is not a dirge – it’s a reveille.

Why might this article be published now? Could it be that after several decades, psychiatry is awakening from a long sleep?  A sleep induced by straying from the path of focusing on patient care, and into the dark woods where a dense pharmaceutical miasma blinded our vision? Awakenings can be painful. We’ll be stiff and groggy as we look around and survey our current situation. But the pain will cause us to become wide awake. Psychiatry is becoming more conscious-–it is setting limits and cutting inappropriate ties to Big Pharma. It is researching new treatments on its own, without biasing influences. It is saying – “we value all the psychotherapy we learned and wish to use it, because it helps our patients.” Good morning Psychiatry! You’ve been asleep for some time now and you’ve been missed. But the good news is that your patients need you and your highly specialized training. But let me warn you-–things have changed while you slumbered. . .

Many of our patients have been relocated. Jails now house more persons with serious mental illness than do psychiatric hospitals.^5-7 Perhaps we might consider a return to the original ideals of our path--the care and well being of persons suffering with serious mental illness, and especially the many who are now in our “new asylums.” The fact is that such jobs are plentiful, lucrative and rewarding. One can practice without any false partitions. Medical concerns, medications, psychotherapy-– all may be attended to by the psychiatrist. The patients are grateful for competent care, and time constraints are far less of an issue. Here is a noble calling and return to psychiatry’s roots. There is great honor in following this path that was originally traveled by names such as Rush, Ray, Pinel, and Menninger, among many others.

I liken our predicament to that of the ancient samurai of Japan. The original meaning of the word samurai was “to wait upon or accompany a person.” One had to serve a long apprenticeship and undergo arduous training. They followed a “code,” and held a prominent place in society for many hundreds of years. But as sure as all things are transient, modernization and changing societal politics dissolved the samurai’s power, value and influence back into the ocean of Japanese society. However, many samurai assimilated themselves into the more modern naval training schools. Some went on to learn other skills and/or teach higher education. It is evident that their culture and philosophy still influence Japan to this day. My point is that they ultimately adapted to inevitable change without giving up on their ideals. It is not difficult to find highly successful Japanese business men who trace their lineage back to the samurai, and indeed refer to themselves as modern day samurai. 

       “…If the fight is for principle and justice, even when failure seems certain… cling to your ideal… and calmly await the conflict.” ¹

- Sir William Osler, MD
 

“It may seem difficult at first, but everything is difficult at first.” ²

- Miyamoto Musashi

As for those who choose private practic-–they too play a critical role. But note that in the Times article, Dr Lance answers to no one but her patients’ needs and her own calling.³  Continuing my samurai analogy, she could be likened to a Ronin-–a masterless samurai. Ronin have an important role, and they refuse to relinquish their honor by lowering their practice standards. They practice to the best of their abilities, but have adapted to the changing conditions. I personally know many such Ronin, and they continue to remind me how satisfied they are with their chosen path. They could not “imagine seeing patients for just 15 minutes” –-and so they don’t. This is their principle, and they stand by it. And in doing so, they are also helping countless patients receive quality treatment. It is also not the case that these Ronin care only for the “worried well.” The Times piece notes that in “New York City. . . a select group of psychiatrists charges $600 or more per hour.”³ But the rarified atmosphere of a top dollar Manhattan psychiatrist’s office is hardly a realistic assessment of the state of private practice in psychiatry.

There is much truth to the statement that “Medicine is rapidly changing in the United States,” and that these changes have been associated with a “loss of intimacy between doctors and patients.”³ This is simply a fact for all of medicine, and so let’s examine this trend a little more closely. Trends in healthcare, generally, could be said to proceed in this fashion:

o Technology never stops progressing;
o As technology progresses, much of the evaluation/treatment process becomes more rapid, and just as importantly...
o It becomes easier for people without specialized training to do. Again, a simple fact because the computer/new technology/etc can do the job more quickly, more consistently, and without a salary and healthcare benefits;
o Thus, the business of healthcare becomes progressively segmented and compartmentalized;  o No area of healthcare is immune to the above process

Psychotherapy does not escape this sequence. Already, virtual psychotherapy is being developed and used. Soon, “avatar therapists” may be implemented.⁸ But until we develop true artificial intelligence, human beings will still be needed somewhere in the process. So in the interim, psychotherapy too will be distilled down to what “researchers” believe is its practical “essence.” Anything that cannot be accomplished in the 10 to 15 minute session can be given as a take home assignment to the patient. At some point, third party payers may decide that it is no longer feasible to pay even psychologists or social workers for what anyone with a bachelor’s degree can do. Is this sounding familiar? If so, it is because some of it is already happening. 

But the question still remains: if we are not satisfied with this, must we accept it? Are we so genteel and apathetic as a profession that we will simply acquiesce? Will we passively assent to a lowering of what we believe is an acceptable standard of care for the patients we took an oath to treat?

Some may argue that my points here are too idealistic. Others may quarrel: “It is easy to proclaim such ideals when one does not have to live with the restrictions of my position.” To them I would say-–who is it that is keeping you imprisoned by these restrictions? Ultimately, this type of thinking provides no solutions and nurtures discontent. All that really matters are the answers to these questions:
1. Are your patients’ best interests being served?
2. Are you content practicing medicine according to the oath you took? 

If the answer to either of these questions is no, then it may be time to change your situation. If we still wish to pursue our medical calling, then we must seek out the set of circumstances that brings us closer to what matters, and settle for nothing less. Such circumstances do exist (albeit maybe not in a particular desired location), and it is still possible to practice this amazing profession provided one is willing to adapt, stand by one’s principles, and stick to the path.

Psychiatry--it is time for you to awaken and return to your calling. If you went into psychiatry for the money, well. . .perhaps it is time to reevaluate that decision. If you went into psychiatry because you wanted to relieve suffering and explore the mystery of the human condition with your fellow travelers/patients, then it is time to stand by the code and ideals of your profession. And if, at some point, you find yourself worn down by the tedium of your routine, consider returning to the source of your principles, where you will find that the beauty and mystery have been awaiting you.

"Nothing will sustain you more potently than the power to recognize in your humdrum routine. . . the true poetry of life…”¹

- Sir William Osler, MD

References:

References:
1.Ossler W. Aequanimitas. 3rd edition. Philadephia: The Blakiston Company, 1947.
2.Tokitsu K. Miyamoto Musashi: His Life and Writings. Boston, MA: Weatherhill, 2004
3.Harris G. Talk doesn’t pay, so psychiatry turns instead to drug therapy. The New York Times, March 5, 2011.
http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?pagewanted=1&_r=4&nl=todaysheadlines&emc=tha23
4. Turner E. Matthews A, Linardatos E, et al. Selective publication of antidepressant trials and its influence on apparent efficacy. New Eng J Med. 2008;358:252-260.
5.Mental Health Law Reporter. State trends: jails are housing majority of mentally ill. 2007; 25(10): 78.
6.Torrey E, Zdanowicz M. Prison and jails are no place for people with mental illness. The Idaho Statesman. November 25, 2002. http://www.psychlaws.org/GeneralResources/article109.htm
7.Lamb H, Weinberger L, Marsh J, Gross B. Treatment prospects for persons with severe mental illness in an urban county jail. Psychiatric Services. 2007; 58: 782-786.
8. http://www.nytimes.com/2010/11/23/science/23avatar.html?_r=1&pagewanted=1&ref=science