Are We Training Psychiatrists to Provide Only Medication Management?
Are We Training Psychiatrists to Provide Only Medication Management?
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.
The following comment was made by Jay Augsburger, MD:
I read with dismay Dr. Weissman's characterization of resident education. In the case of this graduating resident, the answer to his question is one word: no. I am about to complete my training at Oregon Health & Science University in Portland, OR, and his pessimistic description of residency training has little in common with my personal experience at OHSU. I was given a great deal of autonomy throughout my residency and felt that I was a valued member of the treatment team, involved in many elements of patient care, not just medication management. It is unfortunate that Dr. Weissman's perception is that residents are not getting such experiences in managing psychosocial aspects of patient care.
Also, I feel well prepared to treat patients with a variety of psychotherapeutic modalities. Specifically, I have treated outpatients with cognitive-behavioral therapy, interpersonal psychotherapy, and supportive psychotherapy, in addition to dynamic therapy (which Dr. Weissman mentions). Indeed, the Accreditation Council for Graduate Medical Education (ACGME) defines these as essential to resident education: specifically, the program requirements for psychiatry state that the resident "should develop competence in . . . applying supportive, psychodynamic, and cognitive behavioral psychotherapies to both brief and long term individual practice, as well as to assuring exposure to family, couples, group and other individual evidence-based psychotherapies." I believe that my program met and exceeded those recommendations. If Dr Weissman believes that his training institution is not doing so, he should consider contacting the ACGME about these deficiencies.
I am a psychiatric Rn for Kaiser Permanente. I work for seven psychiatrists and the sad truth is that these well educated capable people have been reduced to twenty minute appointments. Some have patient loads of 1000 patients if they have been there for many years. So of course they are reduced to med checks and very little time for any other treatment. It is sad to see and I wonder if it is a function of the population growth, economic survival of HMO's in these times, or just an insurance company that is badly managed where mental health is concerned.
Where is the evidence? I've only been a Psych intern for 2 days and already disagree with the claims in this article.
Dr. Weissman give a good overview of Psychiatric Residency program. In this mechanical age, where billing and dealing with insurance companies also a part of training. When you go into practice you are going to face it. Psychiatry is all about read between the lines, there is no black and white, every human is unique and has his/her own style.
As a mental health nurse practitioner, not working in the US nor a psych registrar etc i humbly add that any opinion expressed by me with regards the training/psych residency program is obviously not based on the experience itself-but observation. After twenty years of psych nursing-albeit not in the US-I resonated with Dr Weissman on two salient points: whether the clinical experiences in training for psychiatry were not leading towards a bias of the medical management model, based on the time given during each rotation towards the science of psychiatry, as compared to that of psychotherapy. And secondly as the art of psychiatry is largely experiential, the formation of a DSM diagnosis made independently-without the same focus given during training to psychotherapy, the confidence one would/should have surely in making a diagnosis would well be affected by this. ie the science, the knowledge being there (in abundance) but not necessarily equating with the independent practice needed to make a confident diagnosis-differential or otherwise. Additionally, basic competencies in therapies-even CBT and supportive short term -are merely that. Just from a nursing perspective the possibility of being considered competent in long term psychotherapy is understandably questionable as anecdotally few advanced registrars either have had the time/sometimes the insight-to do intensive psychotherapy on their own issues-under clinical supervision. Thus when Dr Weissman states the art of psychiatry very much depends on the skills, empathy, the ability to create a therapeutic alliance etc, humbly I think it a valid comment to suggest that the main indisputable competency, mastered by a psych reg IS the prescribing of psych meds. Believing otherwise-based on observation only again as a nurse-there are slippery slopes yet to be foreseen, recognized negotiated and experienced....hopefully not at a board level. Interesting commentary.
I appreciate Dr. Weissman's recent commentary (June 2011 Psychiatric Times) speculating on the direction residency programs have gone in emphasizing psychopharmacology as the only intervention offered by psychiatrists. I have been out of residency for two years and feel lucky to have found ways, as a VA employee, to integrate further psychotherapy training into my work, co-leading a group, and participating in research. Psychotherapy training was available in my residency, but I had to pursure if actively. I am conerned that academic training programs often dismiss psychotherapy because it does not lend itself to lucrative research funding and because of the presesnce of psychology and social work training programs often nearby. Personally I find psychopharmacology interesting, but limited generally in effectiveness even in my primarily outpatient population. I find it impossible to prescribe responsibly without paying attention to the psychosocial factors effecting my patients, in addition to the biologic ones. I have attempted, in precepting and supervising other medical trainees, to emphasize the psychosocial aspects of treatment and enhance appreciation for these. We struggle against unrealistic expectations set forth in pharmaceutical advertisments, recommendations by well intended non physicians to "get your [patient] meds adjusted", and our own high hopes for the newest pharmaceutical compounds. One of our biggests charges is knowing when not to prescribe, and when we cannot, feeling competent to invoke other treatment modalities. Psychiatrists are physician who specialize in the treatment of those with mental illnesses. It's not inappropriate to have a unique niche or interest, but a balance seems imperative given our lack of objective tests and that numerous diagnoses that can masquerade as one another. It does, in residency training, require special attention as not to convey the expectation that psychiatrists only heal with prescriptions. Our patients would want us to be familiar with all evidence based modalities to be able to act in their best interest. I believe focusing primarily on psychopharmacology will create dissatisfaction in the field, perpetuate erroneous and negative stereotypes of psychiatrists by the public, and most importantly not foster knowledge of the widest and best range of potentially useful treatments for each of our patients.