Sunday, June 15, 2014

Psychiatry's Low-Tech Advantage

The other day, I received this in the mail:

It's a 57-page booklet/brochure ("bookchure"?) filled with professional photos designed to tug at the heartstrings, minimalist typography, and colorful charts highlighting the awesomeness of Akron Children's Hospital. All I could think of was, "How much money did they waste on this?" Living nowhere near Ohio, I will never have the chance to refer a patient to them. Pages 51-53 list 6 names on their Board of Directors, 26 Directors, 3 Directors Emeritus, and 5 Honorary Directors. This many Directors, I presume, are needed to oversee the 4751 employees and 703 medical staff (p. 50), as well as $1.06 billion in gross patient services revenue (p. 56).

And this wasn't the first such bookchure I've received. I've gotten similar mailings from the Mayo Clinic, the Cleveland Clinic, and probably other places that I've since forgotten. This is what our health care industry has become: Specialty centers who vie for clientele by boasting about the high-tech procedures and treatments that they offer. It reflects a system where about 20% of the population take up 80% of the costs (and even more damning, 5% of people account for 49% of spending).

At its core, Psychiatry is a very low-tech specialty, perhaps the one least reliant upon machines and specialized equipment. That's not to say there's no technology in the field, since knowledge constructs such as CBT are also forms of technology (and let's not forget Big Pharma), but psychiatry today is generally not what anyone would call "high-tech."

The leaders of academic psychiatry and the director of NIMH certainly view the low-tech nature of psychiatry as a huge disadvantage, a travesty that they are doing everything in their power to try to rectify. Hence the ever-greater emphasis on higher-tech ways of studying and manipulating the brain, whether it's optogenetics or connectomes.

However, I view psychiatry's low-tech nature as a huge advantage, at least when that advantage is embraced. A psychiatrist can easily start a practice due to low capital costs and enjoy low overhead since there is no need for a huge support staff. This keeps the focus on the relationship between the doctor and the patient, rather than having some other intermediary like an insurance company or a managed care organization extracting profit. Patients get to spend more time with their psychiatrist, and the psychiatrist has to see fewer patients, resulting in a win-win scenario. Especially if you believe, as I do, that a good therapeutic relationship can lead to positive changes.

Rather than embrace these advantages, the leaders of our profession have done all they can to minimize them, by advancing and supporting a biomedical model of psychiatry where psychiatrists are turned into prescribers doing brief med checks (or into consultants to other doctors). Since drugs are one of the few high-tech (and expensive) things in psychiatry, this of course serves the interests of pharmaceutical companies and the researchers that they support.

Last week, 1 Boring Old Man wrote about new APA President Paul Summergrad's plea for psychiatrists "to put aside internecine battles":
What [Summergrad's] predecessors have failed to notice is that a growing number of psychiatrists refuse to operate in the world created for them by Managed Care and insurance reimbursement, and that’s not all about money. […] A lot of it has to do with being unwilling to have practice dictated by excel spreadsheets in the offices of bureaucrats, the marketing departments of a corrupt industry, or the moguls of the APA and NIMH. Many avoid the APA like a plague. And many who still work in that system would be glad for a chance to change it into something more compatible with the real reasons they chose this specialty in the first place.
I really like the above paragraph from 1BOM since it captures the essence of the problems within our profession, but I would say that it's very hard to be a part of "that system" without being subject to general economic trends affecting all of healthcare. Most other specialities are not quite as low-tech as psychiatry, but the ones that rely on talking to patients and examining them using very basic equipment, such as internal medicine and pediatrics, certainly have similar dynamics.

With all that said, I am by no means anti-technology, as long as the technology is serving the patient. For example, a recent San Francisco Chronicle article highlights one entrepreneur's efforts to create "a website for a health care model in which members pay monthly fees for primary care." If that works, it would help remove primary care physicians from the grind of being in the current insurance reimbursement-based system, which has led to high rates of burnout. Also promising are the health initiatives of companies like Apple, which have the potential to empower individuals to keep better track of their own health (and allow doctors easier access to that information), which hopefully will someday decrease society's reliance on the high-tech specialty hospitals with their fancy publicity materials.