"Basically, the problem is that doctors have no power or control over our own profession. The reimbursements rates and policies are determined by the government and private insurers. The doctors who are older can tell themselves they only have to stick with it a few more years before retiring, while younger doctors are too busy trying to establish themselves and pay down medical school debt. Doctors can't unionize or go on strike. It's hard to organize them because it's like herding cats. Therefore, we just have to accept the system and work within it."
I thought it was a very good summary of the present situation facing most medical specialties. It was a nice coincidence that the following day, 1 Boring Old Man wrote wrote this post highlighting some of his reactions to recent articles on psychiatrists & insurance panels, as well as whether psychiatrists who do psychopharmacology vs. psychotherapy will eventually split into different professions. He began:
I went into practice around 1986. If patients used insurance, that was fine with me, but for two simple reasons, it never occurred to me to take insurance. First, I would’ve had to have a staff to file it and keep up with it and I didn’t want to pass on those costs. Second, that would’ve required me to be on insurance panels that would’ve prescribed how I practiced, meaning becoming a psychiatrist who primarily prescribed medications – the kind of psychiatrist people rave about in the blog comments, on Mad in America, or on the steps of the APA Meeting in New York.Dr. Dawson wrote the following in response to 1BOM's post:
We will all remain in the limbo of politicians telling us we need increased access and insurance companies decreasing access in order to increase their profitability. And that has nothing to do with the fact that psychiatrists need to be trained in neurology, neuroscience, medicine, and psychotherapy. Not accepting insurance is the ultimate affirmation that business does not define medicine or psychiatry.
In a comment on 1BOM's post, Dr. Reidbord had this to say:
It appears many of us psychiatrists simply got the memo a little earlier. Psychiatry, like primary care medicine, is fast becoming two-tier: practiced at the level of professional excellence when business does not define it, and something tragically less when it does.
What I wonder is, why don't more psychiatrists speak out about the state of things? The difficulty in spurring practicing clinicians to action is vexing, since I believe that the majority of psychiatrists enjoy spending time with patients and did not go into the profession to become 15-minute med checkers or care team consultants who do not directly see patients.
Of course, I think the cardiologist's explanation above is a good one, but additionally, I believe that ideology and zeal are two primary factors that give psychiatrists of the key opinion leader (KOL) variety a disproportionate amount of power. 1BOM has written before about the dangers of therapeutic zeal, while I've written about the NIMH's techno-utopian vision. The problem here is that ideology and zeal are unifying forces that rally people to a cause, allowing them to dictate the course of events even when they are in the minority. It is much harder to get people to rally around the banner of multi-disciplinary thought ("psychiatrists need to be trained in neurology, neuroscience, medicine, and psychotherapy") or the biopsychosocial model. As David Brooks wrote in a recent column on threats to the international system of liberal pluralism:
It was barely possible [to defend the system] when we were facing an obviously menacing foe like the Soviet Union. But it’s harder when the system is being gouged by a hundred sub-threshold threats. […]Can there possibly be a solution? Well, it is fortuitous that at least for psychiatrists, independence is still an option. Unlike many other medical specialities, we don't have to buy expensive equipment or hire an extensive support staff. Solo office-based practice is still possible. In certain parts of the country, people are willing to pay $250 per hour for a psychiatrist who is good with both medications and therapy, though if you're like 1BOM and don't care about income maximization, you can probably work anywhere.
Moreover, people will die for Mother Russia or Allah. But it is harder to get people to die for a set of pluralistic procedures to protect faraway places. It’s been pulling teeth to get people to accept commercial pain and impose sanctions.
And perhaps some day, enough doctors will tire of the "long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism," and declare independence en masse. That'll be an interesting day.