I watched as senior physician partners of multispecialty clinics took the money and ran, selling the futures of their younger partners and new hires to ever-growing systems. I watched as more and more physicians signed contracts with no-compete clauses without realizing or caring that they were giving away control of their destiny. I watched as these no-compete clauses eliminated . . . competition, leaving the owners of the contracts a clear path to design health care according to their own interests. And I now watch as new graduates step lightly off the bus into the only city they will ever know, lacking the frame of reference that is necessary to long for the past.
Psychiatry may be the last bastion of anything that resembles the traditional physician-patient relationship. Perhaps as evidence of what patients truly want, cinematic portrayals of psychiatrists rarely show busy waiting rooms or even office staff. We may be the only specialty that does not assign patients to individual rooms with fluorescent lighting, only to disrobe, wait, and hope that the footsteps in the hall are finally headed their way. Any cursory consideration of the psychiatrist-patient relationship reveals the problems with such an approach. But I doubt that clinic administrators will necessarily see the point, and I will not be completely surprised to one day see psychiatric patients lined up in such a way for the sake of efficiency.
All of these thoughts are assembled in an attempt to explain my intentions— course that will appear quixotic to many. But after all, I do have a frame of reference. And I am old enough to consider it more palatable to take risks to create something special than to work in frustrated security.
It is not difficult to imagine my ideal practice. I want to know the details of my patients' lives, and I want to have the time to sit quietly with them long enough for doorway revelations to arise. I want the time to explain all of the treatment options and to come to a collaborative treatment plan tailored to their individual circumstances.
I want to set my own schedule and my own workload, so that I have the time and energy to offer my full at tention to each patient. I want to make my own determination of appropriate "usual and customary" fees, rather than accept arbitrary payments from businessmen. I don't want to work "on volume."
I want to pick my furniture. I want to implement only the paperwork that makes sense. And I want to make clinical decisions based only on the welfare of my patients, with no help from utilization review nurses. I would rather advocate from the outside than apologize from the inside.
On this note, I start out. I hope that readers enjoy the journey. Perhaps my experiences will encourage those with similar desires to follow their interests. Or perhaps my experiences will provide validation for those who find comfort in their roles as employees/psychiatrists.
A local network psychiatrist assured me that my destiny was not pretty. "You'll never make it—that just doesn't work anymore. Everybody comes to us."