When I’m 64: Howling for Psychiatry

Today, May 5, I'll be turning 64. Normally, that would not seem to be a birthday of particular distinction. Why is it for me?

In 1967, the Beatles released Paul McCartney's song "When I'm 64.” The theme had to do with whether a young man's lover would still need him many years hence. In a broader sense, it ponders the future of any relationship. I started medical school in 1967 and was also engaged in that year to be married in 1968. Fortunately, I don't think there is any question about whether my wife and I still need each other in the highest sense of "need.”

However, if I apply the same question to my profession, I begin to wonder. Take the lyric: "Will you still need me, will you still feed me, When I'm 64?" One meaning of “feed” in terms of professional work can mean “reimbursement.” In our field, not only do more experienced clinicians not get paid more generally, but if salaried, in this age of cutting costs, their higher salaries start to look enticing to be replaced with younger clinicians. "Eat what you kill" was one metaphor for getting reimbursed that I heard not long ago.

Per the song, the question of need goes well beyond feeding or reimbursement, as this verse suggests: "I could be handy, mending a fuse, When your lights have gone." I know I'm not handy at home and couldn't fix a fuse, but what does “handy” mean in terms of 2010 psychiatry? When I started to practice psychiatry in 1975, it typically meant being able to combine psychodynamic psychotherapy routinely with medication in a 50-minute hour. As fellow Psychiatric Times blogger, Dr Carlat, so poignantly described in his April 24 New York Times Magazine article, "Mind Over Meds,” that is no longer the case.

To compound the loss, although we psychiatrists are often relegated to brief medication checks, most psychiatric medications are now prescribed-often ineffectively-by primary care physicians. Over the years I've often wondered why we didn't designate psychopharmacology akin to surgery-both are highly skilled activities best performed by experts. Nurse practitioners and physician assistants have gained some prescribing privileges, and psychologists want to obtain them. The only clinical situation where psychiatrists seem to be clearly needed is psychopharmacology of complex cases.

Psychiatrists are needed less for psychotherapy per se. Other clinicians accept less reimbursement, and cognitive-behavioral therapy is much easier to learn than psychodynamic psychotherapy. It appears that psychiatrists no longer lead most mental health organizations. Other than academic departments of psychiatry, administration is often done by other disciplines, including pure business managers. Unless patients self-pay, whatever we do is usually managed by insurance companies. Less trained reviewers evaluate what we do.

We've even given up responsibility for our own diagnostic manual. Ever since DSM-III came out in 1980, diagnosing was open to self-proclaimed experts of any discipline. Despite all these changes, as I turn 64, I still feel well fed, at least in terms of helping patients in some way. Early career psychiatrists know nothing different and may be more than satisfied with what they can do.

I'm sure I can be accused of the usual nostalgia of the aged for the "good old days.” I still fondly remember my residency at the University of Chicago from 1972 to 1975, when psychiatry was much more involved with the humanities and society than now. When I think back on those times and what seems lost, I feel like howling, as conveyed in Allen Ginsberg's "Howl,” published in 1956, a poem we studied back in 1975. Apropos to us, the poem was dedicated to Carl Solomon, whom Ginsberg met in a psychiatric institution and reminded Ginsberg of the mental illness of his mother. In our seminar on Literature and Psychiatry, we discussed how poetically and persuasively Ginsberg described the lack of effective treatments in 1955, and how far psychiatry had come 20 years later.

Perhaps some of you will recall the famous, seemingly never-ending stream of consciousness, in the best free association Freudian style. The poem starts, "I saw the best minds of my generation destroyed by madness, starving hysterical naked . . ." It strikes me now, that if he still were alive, Ginsberg might howl about what psychiatry has lost since 1975. I hope he wouldn't mind my using poetic license to update audaciously some of Howl:

I saw the best minds of psychiatry stressed by madness, stripped of their skills, by managed care denying care, by government reimbursement too low for overhead, by Pharma tempting with food, trips, and fame . . .

No wonder the editors of Psychiatric Times named this new blog "Couch in Crisis.” We are in a crisis-but as the Chinese definition goes, crisis is both a danger and an opportunity. Do you agree, and if so, what opportunities do you see? As the Beatle's song concludes: "Send me a postcard, drop me a line...Stating your point of view, indicate precisely what you mean to say. Yours sincerely . . . Whoo!"