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).