I grew up in a small mill village in northwest Georgia. When things did not go right, someone got sick, or we had an accident, or we needed a sports physical, we would head around the circle to the entrance to the mill complex, just across the grassy field from my house, and see Dr. Harry Dawson. Dr. Dawson was that old omnipresent breed of physician who had a small self-contained office, seemed to me to always be there anytime he was needed, and could treat anything. He got kids through the measles, mumps, chickenpox, broken arms, flu, the common cold, and of course, that time I dropped the hammer on my brother’s head when we were climbing the tree in the back yard. It was an accident, I swear. He’s fine, thanks.
There are a few Dr. Dawsons left nowadays, but not that many. Same goes for psychiatrists. It is getting harder and harder to simply think, I want to go see my psychiatrist, call for an appointment and actually get one in less than a few weeks if not a few months. There are a few good reasons for this. According to a Forbes article, “Psychiatrist Shortage Escalates as U.S. Mental Health Needs Grow,” there are twenty-eight thousand psychiatrists practicing in the U.S., but three out of five of them are age fifty-five or older. (Here’s looking at me, kid.) As we face more and more angst, shootings, and the escalation of completed suicides, the number of psychiatrists who actually see patients face to face and deal with crises individually in their practices, modern-day Dr. Dawsons, are very hard to find. My patients tell me all the time that they don’t want to come in to see a counselor, a nurse, a social worker, but that they want to see their doctor. I understand this, but as you shall soon see, what I and many of my colleagues are doing in 2020 is far different than what we trained to do in the seventies and eighties. If you need mental health care nowadays, you may see any one of a dozen people who are part of a treatment team of health care providers. Your doctor may be in, at least physically, but he or she may not be available to see you personally.
My workflow, and that of my colleagues, has changed dramatically over the last thirty years.
While in medical school and residency training, my schedule of activities was pretty much set for me. I had simply to show up at the appointed time and place and work and learn. Training, classes, meetings, patients, all were set by a scheduler or training director. I had very little input. There was little autonomy during training.
Flash forward to early practice in the late nineteen eighties, when I was a junior faculty member of the Department of Psychiatry and Health Behavior at the Medical College of Georgia. I was an attending physician at the state hospital, in charge of residents barely younger than me, attended faculty meetings, and had a practice life that was still fairly regimented. I still spent a lot of my time working directly with people, around people, talking with people. Psychiatry at that stage of my life was still a people profession, driven by conversations, interactions, and face to face meetings.
Go forward still to private practice, which I did for about five years. There were personal interactions with my staff and my patients in the office all day long, visits to inpatients in the hospital, and consults sent for patients on the medical and surgery floors. I was still doing most of my clinical work myself, making my own decisions, and deciding how often to see patients.
Next came work at the mental health center that started as a part-time job in 1991 and then became my primary job in 1993. I loved it, and I have never looked back. Oh, I have done work in crisis units, and I have now been doing telepsychiatry for ten years, but my primary mental health center duties are still my most loved ones. The funny thing is, with time, my duties to see patients one to one in the clinic have taken a back seat to myriad other duties, especially since I have been serving as medical director of our center. Individual work (“I want to go see my doctor!”) has morphed into leading a team of other mental health professionals, and even more recently serving as a co-provider in these groups, not even officially leading them anymore. Now in 2020, I supervise a medical staff of thirteen other people, the most we have ever had in my time at mental health. Oddly though, in the past we had as many as five or six psychiatrists working at the center; there are only two of us among these fourteen staff now. I have many very talented advanced practice nurses, nurses, administrative staff, and part-time, locum tenens, and other providers who have helped us take care of patients over the last decade or more.
The thing that I noticed when engaged in a conversation with some of our senior staff last week is that now I do not simply see a limited and finite number of patients, as many as today’s schedule will allow. I do much more indirect and direct supervision, answering dozens of emails each day, talking in real-time on Skype, and otherwise making decisions for patients who I am not seeing directly, at least most of the time. I am relying on the eyes, ears, and assessment skills of the medical staff as they multiply my ability to hear your stories, assess your symptoms, and come up with a reasonable treatment plan that will help you recover. This is both sad and exciting for me. I miss the days of seeing one patient after another, my patient coming in to see their doctor, that most pure of doctor-patient relationships. However, this new paradigm of care allows me to have a much broader reach and treat more people than I ever could alone. That is good. When you need to come in for treatment of mental illness, you may not see the doctor initially, but you will be seen by someone on the team that the doctor is intimately connected with.
What does the future hold? Telepsychiatry is making inroads in hospitals, prisons, jails, schools, and even patients’ homes. Mobile crisis teams go out into the community and meet patients where they are, giving care at that point, not relying on visits to a clinic. Traveling RVs staffed with teams of providers scour the backroads for people who need help. More and more, care is becoming collaborative, as mental health workers are embedded with law enforcement and medical clinics, and medical providers set up shop in mental health facilities. Psychiatrists are learning that they can teach, supervise, and function very well as part of a larger team, reaching far more souls than they could ever do in their simple solo practices.
I think Dr. Dawson would be proud.
Greg Smith is a psychiatrist who blogs at gregsmithmd.
