Two articles in last Sunday’s Post-Gazette regarding the state of psychiatric care in the United States were timely, relevant and vital for the general public to grasp.
One article described the critical shortage of psychiatrists (“Psychiatrists in Short Supply Nationwide”). It included a table of median incomes for the major medical specialties and showed that psychiatrists’ earnings hug the near-bottom of the medical scale. There was no explanation of the economic contradiction implicit in the data, however: From a pure supply and demand viewpoint, a dearth of psychiatrists should lead to a substantial increase in their median income. It hasn’t.
The second article (“Take Action on Mental Health”), written by a psychiatric patient, lamented her great difficulties finding any psychiatrist, let alone one who would accept her insurance coverage. It would appear that many psychiatrists have solved their economic contradiction by unilaterally opting out of insurance networks that set limited fees for their services, and accept only or largely out-of-pocket reimbursements.
It is not easy being a psychiatrist in this day and age. I know from personal experience. I am one.
The stigmatization of individuals with mental disorders, while lessened in recent decades, nonetheless persists, and it attaches in the public mind to psychiatric physicians as well. The relative absence of high-tech diagnostic and treatment procedures in our field, in an era of gee-whiz medicine, also contributes to a less-than-positive attitude toward our profession.
Finally, media presentations of psychiatrists as somewhat disturbed themselves, or carrying on inappropriate sexual relations with their patients or family members of patients, or sadistically subjecting patients to cruel electroconvulsive therapy (quite inaccurate in this day and age), both reflect and reinforce popular biases toward psychiatrists and contributes to an economic disparity with other specialist physicians.
I would like to set the record straight about who we are as psychiatrists and what our true value is.
First and foremost, we are the physicians willing and able to deal with the volatile, often destructive, largely unconscious emotional and behavioral forces which mark the human condition. These symptoms may be depression which incapacitates; hearing voices when no one is there; seeing visions that others do not; paranoid beliefs that others, including fictional others, will attack and therefore must be struck down pre-emptively; destructive impulsivity; inattention and distractibility to the point of failure in school and work; homicidal and suicidal behaviors; incapacitating panic attacks and social anxiety. I could go on and on.
These symptoms often appear chaotic and terrifying, and it is we psychiatric professionals who are trained to diagnose and treat them. These symptoms frighten the public and often frighten non-psychiatric medical professionals as well. The general response, then, is to project the terrifying feelings of one’s own internal chaos, prompted by exposure to these symptoms in persons we know or hear about, onto the psychiatrist and psychiatry; hence, the negative stereotypes and attitudes.
Second, we are the physicians who must listen to patients at length and with great attention, and we are the ones who develop the broadest understanding of both the medical problems afflicting our patients as well as the social, economic, biological and psychological forces bearing down on them. We must maintain a long-term doctor-patient relationship and employ this relationship to heal the symptoms, pains and fears of our patients.
Third, and in part because we spend so much time listening to our patients, we are called upon ever more frequently to also monitor and sometimes treat our patients’ medical conditions. I have treated restless legs syndrome, hyperthyroidism, obesity, elevated lipids, chronic bruxism (teeth grinding) and peripheral neuropathy, among other ailments, with more than minimal success.
It has been observed that many psychiatric patients, even while seeking and receiving excellent care for their mental health needs, neglect their purely medical care. The psychiatrist is in an ideal position to treat both emotional and behavioral issues as well as basic medical conditions. Some psychiatric residencies therefore have begun to incorporate more intensive training in internal medicine into their programs.
Fourth, even in the absence of formal internal-medicine training (in addition to that already received during medical school and internships), psychiatrists are being integrated ever more frequently into multispecialty clinics to work hand in hand with primary-care, internal-medicine and other specialty physicians to ensure that patients’ medical and emotional/behavioral needs are met in a coordinated fashion; that neither patients’ medical nor psychiatric problems are left to fall between the cracks; and that patients are treated efficiently and conveniently in one setting. This welcome change brings psychiatrists back into the medical fold where we truly belong.
Finally, contrary to popular thinking, our patients’ symptoms frequently improve, and often quickly. Many outpatient problems resolve within weeks, sometimes several months. Often this involves use of psychiatric medications alone or in combination with some form of psychotherapy performed by an accredited psychologist, psychiatric nurse or psychiatric social worker. These improvements are not as readily visible as are medical recoveries because, given the unfortunate social stigma, even greatly improved patients may be reluctant to openly discuss their psychiatric and psychological care.
I have much faith in our psychiatric profession and great respect for its practitioners. The medical world and the public need to be cautious about their stereotypes and biases, often misbegotten, and recognize the essential importance of the psychiatrist’s role. If they do, this would encourage more medical professionals to become psychiatrists, which would ameliorate the shortage while improving the availability and quality of care offered to patients.
And, yes, it would help if psychiatrists were more generously compensated as well.
Marnin E. Fischbach practices psychiatry at several locations in the Pittsburgh area and lives in Squirrel Hill.