How American Psychiatry Can Save Itself: Part 2

Keys to Regaining the Confidence of the General Public

by Ronald W. Pies, MD | March 1, 2012

Dr Pies is Editor in Chief Emeritus of Psychiatric Times and Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY, and Tufts University School of Medicine, Boston. He is the au-thor, most recently, of Becoming a Mensch: Timeless Talmudic Ethics for Everyone; The Judaic Foundations of Cognitive Behavioral Therapy; and a collection of short stories, Ziprin’s Ghost. Acknowledgment—I would like to thank Joseph Pierre, MD, and James Knoll IV, MD, for their helpful comments on this essay.

But on an even more fundamental level, I believe psychiatrists must reclaim and reinvent our role as holistic healers—doctors who are as comfortable with motives as with molecules, and as willing to employ poetry as prescribe pills.⁹ When guided by sound evidence, this is not promiscuous eclecticism, but rather what I have termed, “polythetic pluralism.” I favor an expansion of the psychiatry residency to 5 years, so that residents may receive enhanced training in psychotherapy and the humanities, eg, literature, comparative religion, and philosophy.¹⁰ The added year could also be used to provide greater integration of psychiatric and neurobehavioral training. To be sure: this expansion would pose additional financial challenges and require greater sacrifice on the part of trainees, but I believe it would strengthen the foundations of psychiatric practice and enhance our stature as a medical specialty. (Ideally, I would also favor a concomitant reduction in medical school training from 4 to 3 years, with substantial streamlining and condensation of the pre-clinical curriculum.)

Finally, and most important, psychiatry must maintain a single-minded focus on our primary ethical and clinical mission: not the development of elegant conceptual models or ideal diagnostic criteria, but the relief of our patients’ profound suffering and incapacity.¹¹

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by marios efstathiou | May 10, 2012 12:06 PM EDT

Dear Dr. Pies
Thank you for your very interesting article. In my opinion unless we make psychiatry more medically valid with the diagnostic supportive aid of biomarkers there will always be room for uncertainty and doubt for the medical basis of psychiatry, its therapies and future research. I also advocate in the holistic approach of treating patients nevertheless I want to believe that I am providing medicines for the brain, not the psyche, the latter is an abstract concept that makes our specialty vulnerable and scientifically vague.

Marios Efstathiou MD

by Ronald Pies | April 29, 2012 11:31 PM EDT

Dear Dr. Emiliani--

Many thanks for your cordial note and comments! I fully agree with you that "Psychiatry is an integral part of medicine and therefore is a sub-specialty of medicine." Set adrift from general medicine, I see little future for psychiatry; conversely, we need to do more to integrate--or perhaps, re-integrate--with general medicine. In everyday practice, this means being more available to our non-psychiatrist MD colleagues, doing more educational programs for PCPs, and learning from their experience as well. I also agree with the broad-based, multi-disciplinary approach for psychiatry that you describe--which is one more reason to consider a 5-year psychiatric residency! --With best regards, Ron Pies

by NICOLAS EMILIANI | April 29, 2012 4:54 PM EDT

To the Editor:

Dear Dr. Pies,

I have read most of your articles in Psychiatric Times for many years and have enjoyed them as well as learned from them. I hold a great deal of gratitude and respect as well as admiration of your work as editor. For this reason, I am responding to this article since I share your same concerns of how we can save Psychiatry in North America.

In my training as a global Psychiatrist, I have some very basic premises about Psychiatry as follows:

1. I strongly believe that Psychiatry is an integral part of medicine and therefore is a sub-specialty of medicine.
2. Psychiatry, as well as medicine, has a large number of sub-specialties that are holistic and accepted independently and should be recognized as such as well as practiced in this manner in order to serve the field as well as patients and Science. Such as, Psyhopharmacology, Child and Adolescent Psychiatry, Sleep Disorders, Behavior Therapy including CBT, EMDR, etc. Therefore, we should expect that all training centers should cover all of the above skills/subspecialties in order to have a broad base and well-informed Psychiatrist. Unfortunately, this is not being enforced consistently.
3. We also need to drastically reform the APA and probably make it apart of the AMA since the Mental Health Parity law has already been past by Congress but not funded.

I would hope with the implementation of the above initiatives we would be able to motivate more young physicians to choose Psychiatry as a serious and holistic medical specialty.

As for my own personal status, I am a Psychopharmacologist, Addictionologist, Behavior Therapist, with interest in Child Psychiatry, Psychological Trauma, Stress Management which as helped me integrate, understand, and better serve patients.

Cordially,

Nicholas A. Emiliani
Medical Director, Behavior & Stress Management Center

by Ronald Pies | March 14, 2012 1:11 AM EDT

I thank Dr. Geltman for his kind comments, and I agree that the issue of reimbursement is a significant concern for many psychiatrists, especially as regards compensation for psychotherapy. As Mojtabai and Olfson noted,
"There has been a recent significant decline in the provision of psychotherapy by psychiatrists
in the United States. This trend is attributable to a decrease in the number of psychiatrists
specializing in psychotherapy and a corresponding increase in those specializing in
pharmacotherapy-changes that were likely motivated by financial incentives and growth in psychopharmacological treatments in recent years." [Arch Gen Psychiatry. 2008;65(8):962-970.].

On the other hand, with a median annual income of about $163,000 [according to Medscape], psychiatrists do out-earn most primary care docs, endocrinologists, and pediatricians. So perhaps the general public will not be
very sympathetic to our complaints about compensation. Still, I think Dr. Geltman's point is well-taken, and
must be addressed if we expect psychiatrists to continue doing psychotherapy as a major part of their work.
Let us hope we can find other non-monetary motivations, as well, however!

by David Geltman | March 13, 2012 2:13 PM EDT

To the Editor:

Dr Pies' March 2012 piece on the status of American psychiatry misses one key point. We are not reimbursed adequately by insurance plans for talk therapy. I believe this accounts for a good deal of the decline in numbers of psychiatrists practicing psychotherapy, as well as the near impossibility of finding a clinical position that allows psychiatrists to conduct psychotherapy. As long as psychiatrists expect earnings on par with other medical colleagues and reimbursements for psychotherapy are as low as they are, psychiatrists will not be able to afford to practice psychotherapy in private practice or in institutional settings. I believe the economics of modern psychiatry is playing a larger role in shaping our professional identity than Dr. Pies acknowledges in his otherwise excellent piece.

Sincerely,

David Geltman, M.D.
Jamaica Plain, MA
617-971-0074
dg@myblueatlas.net

Article Comment Pages: 1 2 Previous

References

1. Pies RW. How American psychiatry can save itself. Psychiatr Times. 2012;29(2):1-10.
2. Friedman RA. The role of psychiatrists who write for popular media: experts, commentators, or educators? Am J Psychiatry. 2009;166:757-759.
3. Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008;65:962-970.
4. Sartorius N, Gaebel W, Cleveland HR, et al. WPA guidance on how to combat stigmatization of psychiatry and psychiatrists. World Psychiatry. 2010;9:131-144.
5. Pies R, Thommi S, Ghaemi SN. Getting it from both sides: foundational and anti-foundational critiques of psychiatry. Association for the Advancement of Philosophy and Psychiatry (AAPP) Bulletin. In press.
6. Mishara A, Schwartz MA. Who’s on first? Mental disorders by any other name? Association for the Advancement of Philosophy and Psychiatry (AAPP) Bulletin. 2010;17:60-63. http://alien.dowling.edu/~cperring/aapp/bulletin_v_17_2/37.doc. Accessed February 7, 2012.
7. Paris J. The six most essential questions in psychiatric diagnosis: a pluralogue. In: Phillips J, Frances A, eds. Philos Ethics Humanit Med. In press.
8. Pierre J. The six most essential questions in psychiatric diagnosis: a pluralogue. In: Phillips J, Frances A, eds. Philos Ethics Humanit Med. In press.
9. Pies R. Reclaiming our role as healers: a response to Prof. Kecmanovic. Psychiatr Danub. 2011;23:229-231.
10. Pies R, Geppert CM. Psychiatry encompasses much more than clinical neuroscience. Acad Med. 2009;84:1322.
11. Knoll JL 4th. Psychiatry: awaken and return to the path. Psychiatr Times. 2011;28(5)1-6. http://www.psychiatrictimes.com/display/article/10168/1826785. Accessed February 7, 2012.

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How American Psychiatry Can Save Itself: Part 2

Keys to Regaining the Confidence of the General Public

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