Many external forces, I found, serve to spotlight the real and perceived status difference between psychiatrists and other mental health clinicians. Malpractice insurance has been a prime example. As part of my individual policy, I could attach all the other members of the group at very little added expense. For my partners, however, an affiliation with a psychiatrist caused considerable review and revision of their policies. We also learned that in Vermont psychiatrists and psychologists cannot form a professional corporation together because we are not considered to be practitioners in the same field.
Managed care policies have provided other, potentially divisive pressures within our group. Increasingly, for example, my colleagues are being told that continuation of approval for their ongoing cases would require my psychiatric evaluation and approval. Thus, I have become a de facto managed care reviewer within our group. Furthermore, I am routinely granted more liberal managed care reauthorizations for my patients than my Cedar Brook colleagues are for their clients, even though we each have many difficult cases. The potential conflicts within the group from such arrangements could be mitigated if, for instance, I refused to serve as an in-house reviewer, but then we would lose the benefits of case collaboration and, in the end, the patients may suffer. We talk about these pressures often in our staff meetings, which helps remind us that we are all restricted by the managed care philosophy.
Even without these external pressures, it would be a challenge for our group to remain socially and administratively egalitarian, given the real differences in our training, our philosophies and our presumptions about psychiatry.
Take the "issue" of medications. Although none of my partners are prejudiced against or unaccepting of the need for medication in their patients who need drug treatment, joking comments like "Can you get me some Valium?" or "What's the drug rep giving away today?" seem to belie an ambivalent attitude toward medications.
In general, my colleagues have an understandably uneven intuitive feel for what medications can and cannot do, as I have an uncertain understanding of, say, psychological testing or the principles of therapy with a 6-year-old. Their attitude towards medications resembles my attitude toward television: I have no clear idea how it works, I have no real desire to learn how it works, but I'm glad someone has taken an interest because I like having it available.
Similarly, jokes about the financial prowess and political clout of physicians, which were more prevalent in the first few months of Cedar Brook, seemed to convey a message about how physicians are viewed by colleagues in related fields. (An ironic twist to this theme is that Vermont's governor is a physician.)
As we have come to know each other as partners, however, empathy has been replacing misperception. For example, although my reimbursement from insurance for an hour's therapy is usually more than that for my partners, the relatively small discrepancies have helped, I think, to debunk some of the myth of the comparative virility of a psychiatrist's earning power. Similarly, although managed care is at times more charitable to me in reauthorizing care for my patients, my colleagues see and hear how my many insurance frustrations echo their own. And although I sometimes have an easier time seeking or gaining access to new managed care or other provider networks, we have all come to learn that acceptance into a network is as likely to be a dubious or useless honor as it is a benefit to our practices or our patients.
A long wooden footbridge, 12 feet off the ground, connects our parking lot with our front door. To run along the footbridge is an irresistible temptation to the children who come to Cedar Brook for treatment. Every afternoon I know schools have let out when I hear the pulsating sound of their sneakers on the bridge.
All of the forces affecting and influencing my professional life thunder through my day like these footsteps on the bridge. So many times we hear that private practitioners are "dinosaurs" in today's managed health care environment. At times, I admit, I do feel like a hanger-on in some evolutionary cul-de-sac. Yet, as referrals keep coming in, I find myself feeling more and more fit to survive the Darwinian challenges facing psychiatry. Sharing daily life with colleagues I trust and respect better enables me to live with or ignore the "footsteps on the bridge," which in my more optimistic moments I imagine to be the sound of the real "dinosaurs" rumbling off into the mist.