The Bureaucratic Takeover of American Psychiatry: George Dawson, MD, DFAPA


In this interview with Dr Aftab, Dr Dawson discusses how the rise of managed care industry and associated business forces have led to a profound deterioration of psychiatric practice environment in the United States.

Awais Aftab, MD

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

George Dawson, MD, DFAPA, is a staff psychiatrist at the Hazelden Betty Ford Foundation and an adjunct professor at the Hazelden Betty Ford Graduate School of Addiction Studies in Minnesota. He is a past president of Minnesota Psychiatric Society (2009-2010). Dr Dawson received his MD from the University of Wisconsin, where he also completed his residency training in psychiatry in 1986. In his distinguished career as a psychiatrist, he has extensive experience as a clinician, educator, researcher, and administrator. In addition to his current practice, which relates to addiction psychiatry, his clinical interests include acute care, geriatric psychiatry, and neuropsychiatry.

George Dawson, MD

Dr Dawson writes the blog Real Psychiatry, where his goal is to represent the complex reality of psychiatric practice and to correct misconceptions about psychiatry in traditional and social media. He started the blog in 2012 because he felt that “a blog written by a psychiatrist who has no stake in bashing psychiatry and who has successfully treated patients for over 2 decades is long overdue.”1 Dr Dawson is a seasoned psychiatrist, and I admire the authenticity of his voice and the value of his clinical observations and insights. Dr Dawson has been a vocal critic of the managed care industry and has written on his blog about the detrimental impact that managed care has had on the practice of psychiatry. Given the profound ways in which these structural forces have shaped contemporary psychiatric practice, the goal of this interview with Dr Dawson is to examine the bureaucratic takeover of American psychiatry.

Aftab: You have witnessed the implementation and evolution of managed care over these past decades and you have written extensively about this on your blog. Most psychiatrists of my generation likely have little apprehension of the way things used to be. What do you think are the major ways that managed care has shaped and constrained the contemporary clinical practice of psychiatry, particularly things that may now be taken for granted as the new normal but certainly were not normal 30 years back.

Dawson: The biggest single change has been a deteriorated practice environment. When I started out all department heads were physicians who practiced psychiatry and/or did research. Every department had a business manager who did the accounting, but all the decision-making about physician schedules, physician benefits, physician hiring, physician evaluations, department conferences, work flow, productivity, and academic focus was made by the department head. There was little to no business administration input.

I cannot speak for every department but there was definite esprit des corps. My colleagues and I were staffing what was basically a county hospital and catchment area for acute psychiatric problems in the Eastern Metropolitan area of the Twin Cities. We were hospital-based, in the same buildings as our medical and surgical colleagues. We were all members of a multidisciplinary clinic. Our mission was to treat anyone who needed our services irrespective of their ability to pay. We also had the market cornered in low reimbursement services and we did a lot of what came to be known as charity care by the state officials who monitored it at some point. The atmosphere was very collegial, we were all very dedicated to our work, reimbursement was not that important, and we all felt like valued members of the same team.

Changes in Physician Practice Environment in the US in Recent Decades (Figure by Dr Dawson)

Flash forward 30 years, none of that exists. Now there is a centralized control structure that is strictly businesspeople or physicians who identify more as business administrators than clinicians. They basically dictate what physicians will do and how they are supposed to practice. They exert political leverage on physicians to get them to practice in a particular way and if things do not go their way there are usually repercussions. The practice environment is no longer a place of physician inclusivity and pride in the technical and humanitarian aspects of the work. It is a productivity-based model and physicians are no longer treated like knowledge workers. They are treated like replaceable production workers who can be ordered around by business administrators or their surrogates who have essentially no knowledge about patient care.

The average patient has little idea about this atmosphere in which their physicians are working under when they walk into a hospital or clinic.

Aftab: The idea behind managed care is that it is intended to reduce the cost of providing health care while at the same time improving quality of that care. That is a lofty goal, and given how thoroughly this approach dominates health care in the United States, one would imagine that this system has been allowed to proliferate because it has been successful in achieving these ideals. Yet the reality of health care around us is utterly different. Health care is barely affordable and there is widespread dissatisfaction with the quality of care, both by patients as well as providers. What explains this paradox?

Dawson: The idea that managed care is somehow focused on quality is probably 1 of the great myths of the last 30 years. The original attack by these businesses was on fee-for-service (FFS) medical practice. They claimed that FFS was the main driver of medical inflation largely due to unnecessary testing and treatment. They claimed that if FFS could be eliminated there would be high-quality, low-cost health care. In all that rhetoric the outcomes of a large naturalistic experiment, the Medicare Peer Review Organizations (PROs), conducted during the 1980s and 1990s, were ignored. I happened to be a reviewer for the Wisconsin and Minnesota PROs. All reviewers had to be actively practicing physicians licensed in the state where the hospitalizations occurred and were carefully screened for conflicts of interest. Reviewers were not well compensated, and the reviews were infrequent so you could not make a living at it. As reviewers we were charged with looking at all Medicare-funded psychiatric hospitalizations in the state for both utilization and quality issues.

We typically saw hospital records where patients were hospitalized long time, where death occurred, where patient complained that they did not receive adequate treatment, where the hospital attempted to discharge a patient who did not want to leave, and when there were any potential quality issues. To identify quality issues, we had a staff of nurses and a handbook of potential quality issues that they could flag and send to a reviewer like me. A concrete example of a quality issue would be a patient on lithium who had abnormal laboratory determinations that were not addressed or no lithium determinations while they were hospitalized. Reviewers would typically determine if the length of stay in the hospital was adequate or excessive. They would determine if a quality problem needed some kind of remedial action.

The popular press at the time was full of stories about how physicians were prescribing unnecessary tests, doing unnecessary surgical procedures, and generally responsible for the high cost of medicine. The PRO experiment revealed that when you use physician reviewers who are carefully screened for conflict of interest, there is not enough overutilization or quality problems to justify the cost of the program. The PROs eventually shut down on that basis. The problem is now we have managed care companies who are conducting reviews that are based only on utilization. There are no quality parameters. The reviewers are employees of managed care companies using their own proprietary medical necessity criteria. They have been emboldened by legislative initiatives that favor managed care businesses and can practically do whatever they want in terms of denying medical care. There is generally no transparency and no third-party accountability for these organizations.

On the affordability side, high administrative costs are part of any picture where there has been a large escalation in administrators. Himmelstein’s stunning graphic shows that between 1970 and 2016 there was a 3000% increase in administrators compared with about a 200% increase in physicians. I did a cost comparison with Switzerland and demonstrated that if the United States could approximate the per capita costs of even the next highest health care cost nation it would save $845 billion per year. Instead of reducing these administrative costs, the industry looks for more way to increase funding. The most recent twist is to use a political initiative is the high deductible to basically assure a cash infusion into the managed care business and the pharmaceutical benefit manager business before they have to pay anything out. The net result is Americans are paying very high costs for rationed medical care and access.

Aftab: As you look back at the slow takeover of medical and psychiatric practice in the United States by bureaucrats, medical administrators, insurance companies, what do you think are some pivotal moments and key decisions in this history that have led us to where we are now?

Dawson: I started practicing in 1986 at a community mental health center and found it odd that county administrators funding the programs were telling us how to run them. That worsened when I went to a medical center for the next 22 years. In the early years, there was clear cooperation between the state government and insurance companies. I ran into a string of inpatient treatment denials for patients who had severe mental illnesses (SMI) and substance use disorders (SUD). My first complaint was that the individual generating these denials worked for another insurance company and it constituted a conflict of interest. I was told by state officials that they were consultants and not employees of that insurance company so conflicts of interest did not apply.

The state set a high bar for appealing denials of publicly funded patients. The treating physician had to go to a hearing with an administrative law judge in order to make the appeal and nobody had ever done that before. I let them know I wanted to do that hearing. They waited until I had 12 cases on appeal and gave me a court date. I took a vacation day to be in court and they called me that morning to tell me that the judge decided to cancel the hearings and reject my appeals. It was clear to me that these companies could do whatever they wanted, and that they were supported by the state government. The power to just refuse to pay for any care was the first point.

In parallel, there was a burgeoning popular literature attempting to blame physicians for health care costs. The popular press suggested it was overutilization: too many procedures and too many tests. As I previously noted, there was no commentary at all about the PRO finding that physician reviewers without conflicts of interest had not found that to be the case.

I attended a 1994 American Psychiatric Association (APA) Joint State Legislative and Public Affairs Meeting where a managed care industry consultant told the crowd that the goal was to put all the specialists out of business and that included psychiatrists. He said they were just going to “buy out all of the specialist practices” in order to greatly expand primary care.

Of course, the industry really had no intention of doing that. Initially they made primary care physician gatekeepers for specialty care. That lasted about as long as primary care physicians and patients could take it. In order to remain competitive, most health plans decided they needed to limit the gatekeeper arrangement. At that point, they acquired as many practices and specialists as possible to control the means of production. Most large managed care organizations look exactly like my old multispecialty clinic. The only difference is that they are no longer run by physicians. In the end, the cost structure of the clinic was higher due to more administrators, and it required a larger patient volume to cover considerably more overhead. The Governor of my own state Arne Carlson was also at the 1994 meeting and gave a speech about Minnesota’s approach to medical insurance. The message that I have heard repeated a thousand times since: “Things are changing—you have to get used to it.”

Documentation, billing, and coding was a critical piece of the takeover. The billing and coding system in medicine is every bit as subjective as the rest of the field, but now there were large fines against medical centers for violations. I was in a seminar where we were told if the billing and coding did not match the documentation, you could be charged with mail fraud and a Racketeer Influenced and Corrupt Organizations (RICO) violations and end up in federal prison. Teaching residents was unwieldy because there were rules suggesting that the attending documentation had to be as detailed as the residents, leading to demoralized attendings and trainees. The Federal Bureau of Investigation was involved in raiding doctors’ offices to prove these cases. They had their own billing and coding experts.

Just when that system seemed ready to implode, the federal government decided to turn billing and coding over to a compliance arm of respective health care organizations. At that point managed care companies could arbitrarily decide if a physician was billing too much or too little based on a purely subjective judgment and penalize that physician or practice whatever they wanted to. The associated relative value unit (RVU) system also allowed businesses to determine how much they were going to reimburse physicians by adjusting that multiplier. Health care corporations had unprecedented power over medical practices in that they could arbitrarily deny payment or in some cases demand repayment. Medical practices now found they needed extra billing and coding staff just to organize the billing and survive.

In parallel, the pharmacy benefit manager (PBM) business was invented. Now there are hundreds or thousands of algorithms impacting physicians and pharmacists around the game being played between pharmaceutical manufacturers and PBMs focused on maximizing their profits by managing prescriptions. These are the companies who make the rules that a 450 mg tablet of bupropion XL will cost the patient $300/month, but the same medication as a 300 mg and a 150 mg tablet will not cost anything extra. All of these rules lead to a massive problem for physicians with repeat calls and patients running out of medications before a new prescription is approved. The combination of managed care and PBM prior authorizations and utilization review calls from managed care reviewers creates a huge administrative burden for physicians and practices. None of that considerable time is reimbursed by anybody. It is essentially physician time and effort that is used to legitimize an administrative decision based on profit for the managed care company or PBM.

I am reminded of a meeting that an administrator called about a waiting list for an outpatient clinic, and I think it serves as a good example of the sort of atmosphere that exists now in many medical organizations. It was supposed to be a problem-solving meeting and suggestions were solicited from the physicians in attendance. The first 5 suggestions were: “We need more staff.” At that point the administrator said, “You don’t get it. We want all of these patients seen without any new staff.” That typifies management attitude toward physician employees by many of these organizations. The resulting high-volume, low-quality approach leads to low physician and patient satisfaction.

Aftab: It is interesting to see the ways in which complex systems respond to roadblocks in the face of active needs. Let me give 2 examples. One, decisions to reimburse certain diagnoses and refuse reimbursement for other diagnoses incentivizes individual clinicians to diagnose the former over the latter (say major depression vs adjustment disorder, or bipolar II vs borderline personality disorder). This also applies to things like prior authorization. I once attended a lecture by a very well-known “key opinion leader” of our profession who told psychiatric trainees that if the insurance company will not approve a prescription a patient needs for the diagnosis the patient has, then we should give the patient the diagnosis for which it will be approved. Second, the scarcity of substance abuse treatment facilities versus the relative availability of inpatient psychiatric care for emergencies such as suicidality leads to the bizarre situation where individuals with SUD are forced to present their distress in the language of “dangerousness” to get any sort of help from the system. What have your observations been in this regard?

Dawson: Prior authorization and utilization review decisions are always the clearest evidence about how disruptive these businesses are on the clinical process. I really do not like to call them insurance companies anymore because insurance companies stick to business decisions based on actuarial calculations. They do not actively interfere with the day-to-day conduct of their customers or the physicians they are seeing. They do not have anywhere near the conflict of interest that managed care companies do. The fact that managed care companies profit from rationing care is, it should be fairly clear, the most significant conflict of interest within the health care industry.

The advice by the “key opinion leader” in this case is problematic at 2 levels. First, is it really ethical to make a carefully considered diagnosis and then change that for the purpose of reimbursement? I personally do not think it is and in this age where some are concerned about stigmatizing diagnoses, it would probably result in the more stigmatizing diagnosis. Second, as these managed care companies get even more heavy-handed they are calling for prior authorization of generic drugs. I have had to spend days trying to get a drug approved that a decade ago was a 4 dollar a month drug at Walmart. It is clear these companies are interested in maintaining maximum leverage against physicians and patients to the point that they are no longer even reasonable. Approving treatment for only selected diagnoses is all part of that process.

The issue of dangerousness needs to be widely discussed as discrimination against individuals with SMI and substance use problems. Dangerousness is not a diagnosis, but it is the primary reason for which managed care companies allow individuals to be hospitalized in psychiatric settings. In my career I have taken care of individuals who were so disoriented from medical problems or psychiatric illness that they could not find their way out of the hospital and had to contend with managed care physician reviewers who were asking me, “Where is the dangerousness?”

In other words, they were only accepting acutely suicidal behavior or aggressive behavior as being dangerous enough to merit hospitalization. That is an absurd standard that has nothing to do with quality psychiatric treatment. It is the primary reason why there is a nationwide psychiatric bed shortage, a tremendous increase in the number of individuals with SMI who are incarcerated or stranded in emergency departments, and a striking lack of housing resources in the community. Large populations of individuals with SMI are basically being shuttled in and out of psychiatric hospital beds and emergency departments after a few days and sent either to jail or to the streets as homeless only to have that cycle repeat in another few days or weeks. It also removes the ability of psychiatrists to provide specialty treatment services that are consistent with available research. On the outpatient side, the standard infrequent 20-minute medication management appointments also lead to insufficient treatment of numerous conditions.

Substance use treatment is similarly rationed. I see various approaches that include reviewing the patient status every 3 days to determine if they can be discharged. In most of the individuals I see as an addiction specialist, that timeframe does not even allow for adequate detoxification. One of the most striking features of managed care is the elimination of medical detoxification in hospital settings. The enforced managed care standard is that patients presenting to a clinic or the emergency department need to be sent to a county detoxification unit. There are varying levels of treatment available at those facilities and much of it is not medical. Many individuals are sent out from emergency department with benzodiazepines and expected to detoxify on their own. Individuals with opioid use disorders, are sent out with a clinic appointment and nobody has the expectation that they will be able to avoid opioids until that first appointment. Clinic and hospitals who want to develop programs in this area that provide rational and quality care often have to raise funds and have to be prepared to receive inadequate reimbursement, and that is a recipe for a short-lived program.

Aftab: Another odd thing to me is that insurance and managed care companies actively restrict the services that can be offered to patients, and yet they seem to bear no liability for any adverse events that may happen from denial of services. Physicians, in contrast, are potentially liable, or at the very least subject to scrutiny, for anything that may happen to their patients, regardless of whether they had any control over it or not.

Dawson: This is a unique feature of ERISA (Employee Retirement Income Security Act) legislation in 1974. The ERISA preemption clause makes it difficult if not impossible for insured employees to sue their health plan. Attempts at correcting this at both the state and congressional levels have not occurred. There have been lawsuits by individuals but in general the only significant tort action against managed care companies has been by activist attorney generals and in some cases class-action lawsuits. It leaves managed care companies in the position of dictating health care and not being responsible for the outcomes. These companies in effect use physicians as proxies; they restrict the diagnostic and treatment decisions made by physicians, and place those very physicians at risk when there are adverse outcomes. The implicit message from the industry is that if you want the balance restored to physician and patient-centered care, then here we are, you will have to sue us.

Attempts to correct this imbalance occurred in 2008 when the “Mental Health Parity and Addiction Equity Act” (MHPAEA) was passed. With the legislation disparate approaches to financing medical conditions and mental health conditions by health plans were eliminated. In other words, utilization review, prior authorization, treatment limits, and various payment mechanisms were supposed to be at the same level for mental health and substance use disorders as other medical conditions. The “Patient Protection and Affordable Care Act” or Obamacare was passed in 2010, increasing the number of people eligible for insurance coverage of mental health treatment.

Despite those key pieces of legislation, the idea of parity or equal treatment was not being realized. In Wit v. United Behavioral Health (UBH), a class action lawsuit was initiated by 11 plaintiffs representing 50,000 individuals who claimed they were denied coverage based on problematic medical necessity criteria. In the 2019 decision, the District Court of Northern California found that the guidelines used for medical necessity decisions were focused on crisis care and not care specified by professional organizations for the treatment of mental health and substance use disorders. The judge specified 8 accepted standards of care, many of which run counter to what has been happening in managed care for the past several decades. For example, “when there is ambiguity as to the appropriate level of care, the practitioner should err on the side of caution placing the patient in a higher level of care.” This is completely in the opposite direction of most utilization review denials for mental health and substance use disorders since my early experience in the 1980s.

Despite this favorable ruling, the litigation continues with an expected ruling on remedies and then a possible appeal by UBH. For the purpose of this discussion, the ruling is a clear affirmation of everything that I have experienced dealing with managed care companies. The implicit aspect of this decision is that it also recognizes a role for professional guidelines in financing mental health care and hopefully that will stimulate ongoing updates and modifications of those guidelines to the best current evidence.

Aftab: As you know, I have been interested in exploring various sorts of critical perspectives on psychiatry. I have been really struck by how most of these discussions ignore the degree to which many current shortcomings of the status quo are a result of medical practice being constrained by the business side of medicine. Instead of criticizing the system, we see a lot of misdirected anger at individual clinicians and psychiatrists. What has been your experience?

Dawson: That is a running theme on my blog. It is extremely popular to scapegoat psychiatry for “the system” when we know there is no system. The only system in effect at the national level is a system that assures large profits to managed care organizations, pharmaceutical benefit managers, and pharmaceutical companies. Managed care tactics are also employed by state governments to reduce costs. These systems are run by business managers and not physicians.

The system does that by rationing care to insured patients or making sure that those patients pay very large out-of-pocket expenses. When psychiatric departments and hospitals are being rationed, they cannot provide the level of care that psychiatrists are trained to perform. It appears the same companies are doubling down on this strategy by hiring more and more nonphysician providers to match their business model of medical care. The disappointing aspect of all of this is that our professional organizations have never taken a clear position against the managed care industry. Care would be much better if physicians were allowed to take care of individuals the way we were trained. Psychiatric settings are often the most divergent from training settings because of the years of disproportionate rationing.

Aftab: We have seen tremendous growth in community and public psychiatry in recent years. There are formal fellowships in this area now, we have meetings and journal devoted to this. I see a lot of discussion of how psychiatry needs to adapt and meet the challenges of the current health care system, yet I do not hear many of the sorts of critiques of managed care that, for instance, you have expressed over the years. What has been your impression of the rise of community and public psychiatry as a specialized area, and to what extent have our colleagues in this area challenged the dominance of managed care and explored alternatives?

Dawson: I was fortunate enough to have been trained by Len Stein, MD, an innovator in this field. I also rotated through a community mental health center where the community psychiatrists on staff had a continuous presence and there was excellent availability of crisis intervention services. I still remember the seminar where Dr Stein showed us a slide of institutionalized patients in Wisconsin. It was a gymnasium sized room full of cots that had been placed edge to edge. All of the patients wore the same uniform. He told us all that those kinds of conditions in state hospitals led him to come up with the idea that individuals should all be maintained as much as possible in independent living. He designed a number of successful programs to do that. In my first 3 years out of residency I was the medical director at a community mental health center where we also provided those services. So rather than the idea that “psychiatry has to adapt,” I think we need to push the idea that the system needs to catch up with us. Dr Stein and his colleagues came up with the idea for Assertive Community Treatment (ACT) in the early 1970s.

When I arrived in Minnesota in the late 1980s there were no ACT teams at that time. Eventually they developed as Minnesota closed down its state hospitals. From a funding perspective, community psychiatry programs, community mental health centers, and ACT teams are all publicly funded. None of the health insurers or managed care companies pays for these services and it is to their financial advantage when patients move from standard coverage to coverage by state supported services. Getting the services often requires frequent hospitalizations and in some cases civil commitment, even though this could be prevented in many cases by proactive identification and treatment. These services typically employ highly motivated individuals and are very successful at helping individuals live in the community. It is another example of a system of care invented by psychiatrists to provide scientific and humane care that is generally ignored by all of the critics.

Aftab: There is a lot of talk of “structural competence” in medicine and psychiatry these days. Most psychiatrists that I have worked with are very conscious of the complex ways in which social adversity, poverty, and trauma contribute to the psychiatric distress of their patients, yet the system they work in actively prevents them from assuming any role other than that of prescribing medications.

For example, during my residency working with disadvantaged population in outpatient child psychiatry clinic, a very common situation would look something like this: a young child is acting out in class, the mother is working 2 jobs, the father is in prison, the classroom is overcrowded, the school barely has resources. The teachers think this is attention-deficit/hyperactive disorder, and want the child diagnosed and put on stimulants. The mother comes seeking care for the child with that expectation. She is so exhausted that all she wants is for the complaints to stop and for her child to behave. The psychiatrist is not left with a lot of options in a situation like this, especially if other resources (counseling, social work, etc) are scarce. The system has already decided what needs to happen and the pressure is now on the psychiatrist to do what is expected. We focus so much on educating psychiatrists to be competent in many different areas, but we do so little to change the system that makes it nearly impossible for psychiatrists to do a good job. What are your thoughts on this?

Dawson: I agree completely with your characterization of this problem. I come at it from the perspective of being a previous president of the Minnesota Psychiatric Society. In that capacity I was made aware of how we used to have child guidance clinics and residential treatment resources for children with significant problems. Thirty years ago, those resources were at an estimated 300 to 400 beds in the Twin Cities area. Eventually the funding for the residential treatment was eliminated and now the only child guidance clinic available is through a local charity. I heard repeated stories about how child psychiatrists and pediatricians were expected to provide a miracle medical cure to address complex psychosocial problems.

As the number of prescriptions increased there was concern that children were being overmedicated and treated with inappropriate prescriptions like atypical antipsychotics. At that point a consultation line with a child psychiatrist was provided for these prescribers to discuss the prescriptions. At no point were the psychosocial parameters addressed and they still have not been addressed to this day.

The current pandemic will obviously make these situations worse. When I think back to my medical school experience, I did a rotation through Infant Psychotherapy that was run by 2 psychiatrists who I considered to be innovators in the field. We would see parent-child dyads and determine whether psychotherapy might be useful. If we did, our job was to teach the parents how to do psychotherapy with the children. An additional part of that clinic was to travel to see high risk infants and young children in very low-income neighborhoods in the city. A household was identified as high risk if 1 or both of the parents had a severe chronic mental illness.

We also had a weekly meeting where we discussed papers on infant and child development and infant psychotherapy. I did not see a single medication prescribed in that clinic but I did see marked improvement in functioning in both parents and children based on the clinic interventions. As an adult psychiatrist, I have talked to many adults who were placed in residential facilities because of behavioral problems for the old descriptor “delinquency.” Many of these patients tell me that their overriding problem was anger control and that these facilities did help them realize this and get themselves under better control. The elimination of these resources for addressing child and family problems is another natural outcome of rationing practices.

Aftab: This is certainly a frustrating situation for all of us. What do you think psychiatrists can do, individually as well as collectively, to help change this? What course of action would you recommend for us?

Dawson: I have been writing and speaking about this in various capacities for the past 30 years. During this time very few physicians have been interested in a political fight. The only major figure in psychiatry I can recall is Harold Eist, MD, when he was the president of the American Psychiatric Association. Practically all other professional organizations are silent about managed care and pharmacy benefit managers as malignant forces. There is a lot written about burnout and how these companies waste physician time to the tune of billions of dollars a year. Nobody seems to talk much about all the free work physicians have to do to support the conflict-of-interest-driven decisions these companies make. There is some current interest in the Maintenance of Certification (MOC) issue that professional organizations have also ignored. But in general, nothing will happen until many more physicians get activated and unite. There is still the escapist dream out there that “I can still do private practice,” but that is vanishing fast.

After decades of elaborate planning and recommendations, I am back to the beginning. The course of action at this point is fairly simple. There has to be united agreement on the fact that managed care companies and pharmaceutical benefit managers work against the best interests of physicians and their patients. Once that recognition is there, a rational course of action may follow. But it does take physician professional organizations taking a clear stand against these business practices.

I do think there is a lot to be said for specialty clinics that are outside of the administrative scope of managed care companies. The first groups I noticed were radiologists and anesthesiologists. They were followed by surgical specialists. I do not see many large free-standing psychiatric practices. I think it is possible to practice with a group of like-minded psychiatrists and provide excellent care based on an agreed upon practice style that will result in greater degree of professional satisfaction than is possible as an employee of a managed care company. The required business expertise and planning is a deterrent to most but knowing what I know about the landscape today I would have tried it much earlier in my career.

Aftab: Thank you!

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric TimesTM.


1. Dawson D. Why this blog? Real psychiatry: the reality of psychiatry rather than the perception. February 20, 2012. Accessed November 10, 2020.

Dr Aftab is a psychiatrist in Cleveland, OH, and clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric TimesTM Advisory Board. He can be reached at or on Twitter @awaisaftab.

Dr Aftab and Dr Dawson have no relevant financial disclosures or conflicts of interest. Dr Dawson’s blog Real Psychiatry is non-commercial, not-for-profit, open access, and he pays for all expenses out of pocket.

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