A reader in the commentary here asked me if I think “psychiatry is salvageable.” This is a timely question that requires careful consideration.
First, I’ll examine this question with regard to my personal life. Then, I’ll explore this question from the broader perspective of psychiatry as a profession. Finally, I’ll move beyond the topic of psychiatry.
I doubt that the practice of psychiatry is “salvageable” for me. The practice of psychiatry, within the medical systems of today, no longer holds the original appeal it had for me.
When I first opened my private practice in 1989, I enjoyed therapeutic relationships with my patients. I had fun exploring creative approaches to improve each individual’s life. Few medicines were available. Patients paid me. Third party payment schemes were between the patient and his insurance company.
All of medicine has been transformed by two intertwining corporate maneuvers: the takeover of the practice of medicine by medical service provider corporations and unrestricted drug marketing campaigns. By these two powerful forces, the practice of psychiatry (and all of medicine) has been transformed.
Over the past twenty-five years, my role as a psychiatrist has been changed by the impact of these conjoined twins. I was one half of a doctor-patient relationship then. I’ve been re-formatted into an interchangeable cog inside medical service provider corporations. My function is limited to pushing the stream of pills from manufacturers to consumers.
The heart of the therapeutic relationship was ripped out of modern psychiatry. It was replaced by “preferred provider panels” and pre-authorization clerks on 800 numbers. Drug marketing campaigns caused an explosion of demand for pills.
The practice of psychiatry is now a factory job with nothing but prescriptions to offer strangers.
To say that this is dispiriting work for me would be an understatement.
If I still had my old federal student loan enforcement friends chomping at my heels, I would feel more compelled to hunker back down with my prescription pad. But I’ve spent my entire adult life sawing myself free. Those of you that still carry two-home-mortgages-worth of student debt with you into every life decision know what I mean: debt shackles.
There’s still an ocean of suffering to relieve. Allowed only my prescription pad and a time clock, I’m inadequate to the task. I drown when I try.
Now for a bigger picture.
When I was asked if I thought psychiatry was “salvageable”, the question caught my attention. I had to think more about this question than just my own small self, embedded in medical systems.
I had one of those “a-ha” moments.
Psychiatrists are not the only providers trapped in the dance of prescribing psychiatric drugs. More and more psychiatric prescribing isn’t done by psychiatrists.
Along with the ramped-up demand for pills caused by direct public and direct physician advertising, there has been a decades-long marketing campaign to promote the idea of a “psychiatrist shortage”.
I’ve been hearing about this “psychiatrist shortage” as part of the “doctor shortage” story since the early 1980′s when I finished medical school. After residency there was stiff competition for paying patients, hourly contract jobs and salaried employment. Just like today. I saw no evidence of a shortage.
This “psychiatrist shortage” was the rationale given for licensing nurses to be “prescribers” in Oregon. I was told they would work in under-served areas and that they would take the “easy” patients so that overworked psychiatrists would have time to manage the more difficult cases.
A commenter in an earlier blog said that they use physician’s assistants and nurse practitioners where he works for “prescribing” because they cost half as much as psychiatrists. “Prescribing” is what psychiatrists do there. These other “prescribers” are cheaper. Choosing a cheaper “prescriber” cog is a simple financial decision for a corporation.
Most “prescribing” in Portland mental health clinics is done by nurse practitioners and physician’s assistants, not by psychiatrists. Is this different anywhere else?
There has also been a methodical shifting of mental health “prescribing” out of the mental health clinics to primary care doctors and pediatricians. This movement is pushed by shifts in government funding. These patients no longer have access to non-pill mental health treatments.
Both social workers and psychologists have lobbied for “prescribing privileges” in Oregon. Both lost round one. Social workers and psychologists might charge less than nurses to write prescriptions. If it’s “cheaper” to have non-medical “prescribers”, money will do the talking.
Psychologists in two states and in the active duty military can now prescribe psychiatric drugs. It could be an interesting piece of research to discover how much of the funding for these initiatives came from drug companies.
Psychiatrists are completely disposable today. In their diminished role as “prescribers”, psychiatrists are interchangeable pill pushers. Every psychiatrist could vanish tonight and there would be no change in the workings of the machine. The other “prescriber” cogs with their prescription pads would keep the pill-laden conveyor belt moving from pharmaceutical factories and down the waiting American throats of all ages.
Pharmaceutical profits would continue. Prescriptions would be written and refilled. Plus, there are social workers and psychologists clamoring for “prescribing privileges”, ready to help.
Psychiatry as a profession is finished.
What has happened to psychiatry is one small piece of what is happening throughout the field of medicine. The practice of medicine is one step behind psychiatry on the conveyor belt to the scrap heap.
Most physicians are now employees of medical corporations; either direct hires or members of provider panels. They are being downgraded into “prescribers” as well. They have had the heart of the doctor-patient relationship ripped out. They obey rigid formularies made up by the medical corporation bosses in their “prescribing” decisions and race to the time clock.
“Prescribing” as fast as they can, physicians can’t keep up with the artificially created demand for pills. Medical corporations have their own cost saving “prescriber” extenders to help them with this “physician shortage”: nurse practitioners, physician’s assistants, nurses, midwives and expanding pharmacist scopes of practice. Medical assistants, secretaries and software programs authorize refills working from standardized guidelines.
Last year, lucky for overworked Oregon physicians, naturopaths, with their newly expanded “prescribing privileges,” can join as full-fledged corporate cogs at the pharmaceutical conveyor belt.
Thanks for reading and thinking and writing.
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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.