The erosion of psychiatric training has consequences

One of my most vivid memories of medical school was during my internal medicine rotation, when it had become apparent to me that, despite spending my pre-clinical years studying complex pathophysiology and pharmacology, and the fine art of history-taking and the physical exam, the actual clinical work seemed to be more like a numbers game. I felt like I was always responding to a data point: a blood pressure reading, a glucose level, a WBC count. And the response always seemed to be the same: I prescribed a drug.

To my immature medical mind, it seemed almost too simple. I thought a computer could do it just as well. When I commented to my attending physician that we seemed to be emphasizing medications over lifestyle changes, alternative therapies or preventive measures a patient might take, he responded, “We’re doctors. We prescribe drugs. That’s what we do.”

Fast forward about 10 years. I now work part-time in teaching hospital. One of my responsibilities is the supervision and training of psychiatric residents and medical students. Recently, one of the students asked whether her final exam for the psych rotation would include questions about psychotherapy, to which my colleague responded (and yes, this is a direct quote), “No. We’re doctors. We prescribe drugs. That’s what we do.”

The echoes of medical school resounded loudly. But the words from med school professor had had a very different impact on me a decade ago than those spoken by colleague just last week. While I accepted my professor’s words as the insight of a seasoned expert about what really matters in medicine, my psychiatrist colleague’s comments rubbed me the wrong way.

It made me wonder, has medicine changed? Or have I?

I (and numerous others) have written extensively about how psychiatric drugs don’t work nearly as well, or as frequently, as advertised. Others have written eloquently about the inherent dangers of psychiatric medication—a viewpoint which has been, at times, exaggerated, but to which I have become more sympathetic over the years. These are two reasons to shudder at the fact that psychiatrists-in-training are being taught to emphasize the pharmacological approach.

But more important to me is the fact that, with comments like these, we psychiatrists are actively positioning ourselves to rely on a treatment philosophy that may well have run its course at some point in the not-too-distant future. (Will today’s psychopharmacologists face a fate like those of the psychoanalysts of the 1950s and 60s?) If students and residents increasingly see psychiatry as a pharmacology-oriented specialty, they will be less likely to explore other interventions that may ultimately prove to be more helpful to their patients.

Psychiatry is already ceding territory to other professionals. Psychotherapy is taught in most psychiatric training programs, but few psychiatrists are paid (or choose) to do therapy. Understanding how to provide systems-based care, or integrate psychiatric care into a patient-centered medical home (PCMH) model, is not something psychiatrists are trained to do, despite the obvious drift of American medicine in this direction. Even some areas that could arguably be considered areas of unique psychiatric expertise— developmental disorders, addiction treatment, child development, geriatric neuropsychology, psychosomatic medicine, integrated pain management, trauma recovery, to name a few—aren’t a major part of the psychiatric curriculum. Why not? There are no drugs that we can prescribe (and, similarly, no drugs approved by the FDA) to treat these conditions.

This gradual erosion of psychiatric training has two consequences. First, it opens the playing field to other mental health professionals who can generally provide their services more cheaply than psychiatrists do. While most of these specialists perform their jobs quite admirably (making the psychiatrist irrelevant, by the way), the prioritization of cost over quality may result in patients getting worse care over the long run, especially if rigorous standards are not upheld. Secondly, because meds are still where the money is, more non-psychiatrists are getting into the psychopharmacology game. Psychiatric nurse practitioners (who have prescribing privileges), physician assistants, family practice docs, Suboxone jockeys, psychologists (in some states), and many others see psychopharmacology as a way to keep their patients satisfied and to keep their offices full. When, in the end, the data show that these patients fare no worse (or, sadly, no better) than those seen by psychiatrists, then the writing will really be on the wall for most of us.

Some readers, particularly those working in a private practice setting, might respond, OK, I see your point, but some psychiatrists really do provide comprehensive, thoughtful care to their patients. To which I would say, yes, but they are truly in the minority. My own career trajectory (as well as my personal life) has taken some unexpected turns, and these turns have taught me how psychiatry is practiced among the masses in “the real world,” not in the Ivory Towers of Cornell, Stanford, or UCLA. For the majority of patients and providers, psychiatric treatment is a numbers game, and the numbers are easy to follow: More patients + More appointments per day + More medications prescribed = everyone wins.

I believe that not only can psychiatrists provide better care than the medication-laden treatments we dole out today, but we have a responsibility to do so. Four years of medical school and four years of residency provide plenty of time to learn about human behavior, emotions, the roots of motivation, child development, family systems, learning theories, interpersonal skills, coping strategies, evolutionary psychiatry, ego psychology, personality theory, human sexuality, spirituality, existentialism, psychodynamic principles, and basically everything else that makes a person tick, in addition to the basic biology of the disorders we diagnose and treat. To dismiss this in favor of a medication-oriented curriculum that could be obtained in a weekend seminar or in an industry-funded CME course, is an insult to our intelligence, and, potentially, the downfall of our profession.

When the prescription pad becomes a hammer, then every symptom starts to look like the proverbial nail. Perhaps it’s time for psychiatrists to dust off some other tools before it’s too late.

Steve Balt is a psychiatrist who blogs at Thought Broadcast.