As I discuss career options with a group of third-year medical students, I imagine a marketing brochure for psychiatry residencies in a world of mental health parity:
The brain is undeniably the most complex organ of the human body. Beyond controlling virtually all body functions, the brain is the source of the mind, which is but an ethereal concept, so hard to grasp that even the language of mental theory requires methodical parsing. Treatments for diseases of the mind and brain require the intricate understanding of chemistry, physiology, and anatomy that is common to all branches of medicine and also the ability to step outside of oneself and objectively observe personality and emotion. The psychiatrist must tolerate the unsettling awareness of the mysterious relationship between mind and matter and must help others find their own answers to the mysteries of the human condition. The shortage of physicians willing to engage in this area of study reflects the enormity of the challenges. Some medical students become cardiovascular surgeons, the plumbers of medicine, while others choose to nail bones together, taking pleasure in the simplicity of hand tools. Still others find a good living looking at see-through images of body parts—often a day or 2 after the images have been used and care has been provided. These tasks pale in comparison to the labors of understanding and treating diseases based in the final frontiers of medical knowledge. No wonder that the masters of medicine—those who work in the vast field of interventional psychiatry—are so valued by society.
The time has come for my transition from psychiatric residency to psychiatric practice. Not surprisingly, we graduates have encountered great demand for our services; the posting of resumes on Internet boards results in a slew of telephone calls from eager recruiters. For my younger colleagues, the prospect of 6-figure incomes suggests reward, at last, for years of work and debt. Most job offers come from health care systems looking for someone to prescribe medication to complement their bevy of lower-paid psychotherapists.
Under the guarantee of income and benefits lies the expectation of productivity. This productivity is not measured by patient satisfaction, symptom improvement, or reduced morbidity. Rather, the name of the game is the relative value unit, or RVU. The way to get more RVUs is to see more patients in whatever time is available. While many residents long for the independence to practice as they see fit, their debt loads require more practical approaches. Concerns over production and practice limitations pale in comparison to long-delayed plans to start families and buy houses.
For my part, I am grateful for the opportunity to earn good money in the service of a challenging and rewarding career, but I am also aware of the striking difference between the salaries of psychiatrists and the salaries of many other physicians. As a former practitioner in one of medicine's more lucrative specialties, I find myself comparing my apparent value now with my value then. Why is my work now worth less than half as much as my work as an anesthesiologist?
At the end of a night in the crisis service last week, I walked past a group of patients huddled in the cold, waiting for the doors of the walk-in clinic to open. As I looked at their tired faces, I realized the desperation they must feel that compels them to leave their homes or homeless shelters at such a cold and early hour and make the trek to the clinic by foot or by bus. Their pains were certainly as great as the pains of any of my patients presenting for surgery. But for some reason, there is less outrage over their lack of care than there would be for a group of patients with untreated diabetes, appendicitis, or heart disease standing outside a hospital. I realized that like many in society, I had unwittingly accepted the scene before me as representing adequate care for the mentally ill.
The RBRVS, or resource-based relative value scale, was instituted by Medicare in 1992 in an attempt to standardize payments for physician services. RVUs are assigned to physician services based on 3 main factors: physician work, practice expenses, and the cost of liability insurance. Physician work is determined by several factors, including time required for the service, technical skill and physical effort, mental effort and judgment, and amount of stress experienced by the physician from the risk to the patient. To arrive at the fair value of services, the number of RVUs is multiplied by a universal dollar value and adjusted slightly for practice location, according to regional cost of living indices.