The recent New York Times article 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.