In reviewing the practice patterns of psychiatrists today, it is clear that many provide mostly medication checks or medication management for their patients. The conventional wisdom for this model of practice is that it is based on current methods of payment for clinical service, which places a premium on brief interventions by psychiatrists. Medications must be prescribed by a physician, while a non-MD mental health worker can provide psychotherapy and be paid by an insurance company at a lower unit cost than that paid to a psychiatrist to perform the same form of treatment.
Although it is true that today’s economics encourage the practice of medication management by psychiatrists, the current structure of clinical experiences in residency training programs may also serve to implicitly encourage and support this model of practice.
The practice of psychiatry is the merger of scientific disciplines that inform us in understanding behavior and caring for our patients. The science of psychiatry is taught effectively in most, if not all, psychiatric residencies by a graded curriculum that addresses the biology, psychology, and social factors of human behavior. Resident performance on the psychiatric resident training examinations (PRITE) taken during each year of residency and the written examination of the American Board of Psychiatry and Neurology for certification confirm that current graduates are well versed in the varied aspects of the science of psychiatry.
The art of psychiatric practice is learned by residents during various supervised clinical rotations. Each rotation has a number of stated learning objectives and related competencies that a resident must master. But once the resident masters the required competencies, is he or she in fact able to perform these required competencies? The ability to perform in a clinical rotation may not mean that the resident has the competence to practice unsupervised. In assessing performance during or after a rotation, we must determine whether the resident will be able to practice in the field.
While one learns science in an academic framework, the art of psychiatry is learned experientially, in graded supervised settings. The skill set grows with increased experience. In psychiatry more than any other medical specialty, the art of being a psychiatrist is most critical. The psychiatrist’s core knowledge, skills of interviewing, and his or her empathic capacity serve as the diagnostic imaging and laboratory tests of other medical specialties.
The only activity that the psychiatric resident is able to master . . . is . . . prescribing medication . . .
The psychiatrist performs a diagnostic assessment by talking to the patient and to individuals in the patient’s life. After completing the diagnostic interview, the psychiatrist may obtain information from other professionals and from laboratory results. A unique form of information for psychiatrists regarding their patients, which is frequently not acknowledged in both the diagnostic and therapeutic process, is the psychiatrist’s empathic sense of the patient. Using all the collected data, the psychiatrist makes a DSM diagnosis and answers any special concerns regarding the patient. At this point, a treatment plan is developed. Assessing patients and developing and instituting a treatment plan is the essence of the psychiatric residency.