Wednesday, August 18, 2010

How Many Psychiatrists Does It Take?

In his article in the most recent issue of Psychiatric Times Daniel Carlat, M.D. estimates that we need 45,000 more psychiatrists in the United States. In the article Pharmacists Take Larger Role on Health Team we read that pharmacists could be part of the solution to that problem as they assume roles that were once the sole province of physicians. What is missing from Carlat's article (but may appear in his references) is an estimate of how many patients a single psychiatrist can treat. Carlat advocates at the same time for psychiatrists to do more psychotherapy, but we can't have our cake and eat it too. A psychiatrist who attempts to do traditional psychotherapy and 45-50 minute sessions while also treating patients with medication or other biological interventions will not be able to manage nearly as many cases as a psychiatrist who delegates psychotherapy duties to non-prescribing professionals.

Carlat's solution to the problem of too few psychiatrists, training psychologists in the role of psycho pharmacotherapist, will perpetuate the inefficiency of psychotherapists attempting to manage biological treatments at the same time, though there will likely be more of them. In his article Carlat's justification for training psychologists to do medication management rather than recruiting more advanced practice nurses and physician assistants is his unsubstantiated notion that psychologists will be better able to handle what he calls "tough cases." If by tough cases he means the ones that do not improve with first line treatments, it is unlikely that more psychological training will help. If he means patients whose personalities interfere with their treatment, we need to keep in mind that personalities can interfere with all kinds of medical treatment. Perhaps we should train psychologists to treat diabetes and do knee replacements and colonoscopies, too.

While Carlat and others push for combining psychotherapy with medication management another trend would seem to push in the opposite direction. As more and more prescribers give up psychotherapy some would seem to take on the role of primary care provider (We don't seem to have enough of them either.) for their psychiatric patients. This role arguably demands physical examination of patients which the vast majority of psychiatrists gave up as soon as they finished residency. Of course physical findings have little if any bearing on any psychotherapy, but psychodynamic and psychoanalytically oriented psychotherapists seem to have particular difficulty with the so-called "transference" implications of so much touching and seeing on the psychological treatment.

I believe we have plenty of non-prescribing psychotherapists now and that those professionals are at least as capable as their physician counterparts. I believe physicians remain the most capable of prescribing. I also believe that much of the impetus for psychiatrists to continue providing psychotherapy comes from the psychodynamic school and that for many psychiatric patients such an approach is either completely unnecessary or maybe inferior to cognitive behavior therapy or other psychotherapies. However, I believe that improved psychotherapy skills will make for better psychiatrists. We need to develop greater efficiency in incorporating psychotherapeutic interventions into psychiatric contacts. This will require us to relinquish the traditional 45-50 minute session (Today much of such sessions is already occupied by administrative activities anyway.) in favor of a model that incorporates directed psychotherapeutic interventions into a 5-20 minute medication management visit. Furthermore, all physicians would probably benefit from learning some of these interventions.

Which direction will psychiatry take? Will it return to psychotherapy as a core service or become even more medical with performance of physical exams? Or will psychologists, nurses and pharmacists take care of the psychiatric patient of the future?

Maybe we won't need psychiatrists. If we don't make psychiatry more attractive by eliminating burdens from regulation, low fees and payer contracts we won't have psychiatrists.

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