Do We Need Psychiatrists?

November 1, 1999

For a couple of years, I have been a member of the American Society of Clinical Psychopharmacology (ASCP). I guess many of us carry this need to belong from our adolescent years. It always felt good for me to be a part of a professional group, sharing the same interests, united by special education and knowledge. How wrong of me!

For a couple of years, I have been a member of the American Society of Clinical Psychopharmacology (ASCP). I guess many of us carry this need to belong from our adolescent years. It always felt good for me to be a part of a professional group, sharing the same interests, united by special education and knowledge. How wrong of me!

To my great surprise, I recently read an ad for the ASCP exam, which said it was "[wide] open to M.D.s and D.O.s currently Board Certified in any medical specialty..." The ASCP defends this offer by saying that if they catered to just psychiatrists, HMOs might charge this exam with being self-serving. What a wonderful opportunity for all M.D.s and D.O.s to get a license for pill-pushing and also please the HMOs.

However, this is also damaging to the quality of psychiatric care. Why don't we go a step further and start a series of exams, also open for everybody: for oncology medications, for hysterectomies (truly, not that difficult) or, if surgery is a bit of a stretch, how about laser treatment-for everything from wrinkles to cervical erosions. Why not?

If anybody could read a couple of books, resurrect vague recollections of a month-long rotation in psychiatry and start psychopharmacological treatment, why can't psychiatrists learn how to flip switches on laser machines? It's an easy procedure, after all, and if a psychiatrist does not suffer from hand tremors, success is guaranteed.

We can even think about a new specialty: "psychiatric dermatology" or "dermatological psychiatry." Who cares about diagnostic workup and indications for treatments? These subtleties cannot be compared with more important things like HMO revenues and crafty practitioners.

Why do we need residency programs-especially psychiatric residency programs-at all? If it is so easy to treat psychiatric patients, and credentials are given to M.S.W.s and M.F.C.C.s, why do we need psychiatrists at all? We can give a drug license to A.P.R.N.s (Advanced Practice Registered Nurses) or even M.S.W.s. Psychologists are currently fighting for the right to prescribe medications, and it is just a matter of time before they win. And why not? It's cheaper, which should please HMOs even more.

Who really cares that, for example, in my practice every week I see children worsening after being treated with methylphenidate (Ritalin) or another stimulant prescribed by a pediatrician. Pediatricians may not know (and do not necessarily have to know) the difference between attention-deficit/hyperactivity disorder (ADHD) and bipolar or psychotic disorder. Therefore, they may have only one cookie-cutter diagnosis: the ubiquitous ADHD. A busy pediatrician does not have time to pay attention to such "trivialities" as poor eye contact or weird noises or something else not fitting the ADHD framework. Psychiatrists, on the other hand, do have time and are trained for a sophisticated diagnostic workup, but in the rush of managed "care," nobody wants us.

I consider this open-door policy highly unethical and damaging to the position of psychiatry as a medical specialty. No doubt, this trend of encouraging nonpsychiatrists to dispense psychiatric medications and treat psychiatric conditions will further undermine the value of psychiatry, give even more control to HMOs and, most important, cause irreversible damage to psychiatric patients. Subsequently, we will see more sick days, disabilities, admissions, suicides and homicides, and, of course, more litigation. What appears to be cost effectiveness will cost much more in the long run-lack of expertise in medicine never pays back. We must set boundaries between medical specialties if we wish to prevent substandard care. Isn't it time to protect psychiatry, so it does not end up an "endangered species?" Of greater importance, isn't it time to protect our patients?