I was recently speaking with a colleague, much younger than I, who
suggested I blog about what psychiatric practice was like in the “old days”.
She thought is would be of interest to my audience. Not comfortable with
the inevitability of making comparisons, I tucked this suggestion in the back
of my mind. Comparisons are highly personal as each of our experiences
is determined by where and who we are, what we value or disavow, and
the outcomes of what we did or didn’t do. The extent to which I can
generalize is limited to my perception of the thoughts and feelings of
colleagues and to what I read in journals or the news.
It seems that as we get older there’s a natural tendency to idealize the
past. Is this just a matter of taste in what we value or is it difficulty
mastering the changes that inevitably occur, or both? When I was in a
position of supervision, as CMO of a psychiatric hospital, I would cringe
when I heard junior colleagues, mostly non-MD’s, bemoan the passing of
what we used to be able to do (long-term inpatient treatment) in front of
new hires. I’d be thinking that the new hires would be worrying about what
they were getting into. Not a good way of introducing newbies to our
mission. But there was truth in the fact that in the old days we had time
and found satisfaction in getting to know our patients deeply and discussing
their problems and best treatments with colleagues.
It’s also challenging for me to separate out the condition of our professional
world with the world at large. Life for much of the world remains nasty and
brutish, though I hear it’s been getting better over the last few centuries. In
recent years, perhaps around the start of the new millennium, crises of
various types seem to be accelerating. We see their effect on our
population’s mental health, which has clearly been deteriorating.
Several weeks ago I came upon an article in the NY Times, referenced
below, that motivated me to go ahead and write about the “old days”. For
me these were the years in the mid-to-late ’70’s through early ’90’s, before
Managed Care was ubiquitous. The article brought to mind several
severely schizophrenic patients and one bipolar patient (who blinded
himself with a gunshot to his head) that made astonishing recoveries with
the help of long-term (several months) hospitalization, antipsychotic and/or
mood stabilizing medication, and enough time to appreciate their improved
state of mind and to develop trust in their caregivers, with whom they would
continue outpatient treatment.
The Times article featured the beneficial effects of long-term
“hospitalization over objection”, along with appropriate medication, for
several chronically homeless people who were a danger to themselves
because they couldn’t meet basic needs, such as coming in from sub-zero
weather. With such intervention, several mentally ill homeless patients
were able to stabilized and get into permanent homes. In the “old days”,
when there were still some hospitals able to keep psychiatric patients
substantially longer than the 5-7 day stays common today, I had little
compunction about declaring a patient self-endangering by virtue of their
inability to take care of themself. The recent case of a chronically mentally
ill homeless man, a “frequent flyer” in the mental health system, who made
himself a nuisance on the NY subway and was subdued/strangled to death
by a concerned citizen, was an outcome that could have been avoided with
such an intervention.
In the “old days” our treatment options included psychoanalysis,
psychodynamic psychotherapy, group therapy, family therapy,
psychopharmacology, and ECT. With these options one could be a
generalist or a specialist. My residency at Georgetown provided training in
psychodynamic therapy (several of the staff were psychoanalysts),
supportive psychotherapy, group therapy, family therapy (we were fortunate
enough to have Murray Bowen and his acolytes teach us Family Systems
Therapy), and psychopharmacology.
My understanding is that today’s training programs focus less on
psychotherapeutic treatments and more on somatic treatments than in the
past. This is consistent with the economic factors that have led to
psychotherapy primarily being practiced by non-MD’s and psychiatrists
providing shorter “medication management” visits. It seems that in the old
days it was easier to be a generalist practicing various forms of
psychotherapy along with prescribing meds, as I did early in my career.
Here’s something that could only have happened in the “old days”.
In my early practice I did re-evaluations of involuntary patients at Chestnut Lodge, a venerable and no longer existent private psychiatric hospital in Rockville,MD, where Harry Stack Sullivan had been on staff in even older days. I
recall reviewing a chart on one of the Lodge’s patients, reading notes
written by Frieda Fromm-Reichmann, another hero in the pantheon of
psychoanalysis. The pages of the chart were yellowing and friable, but the
patient still needed involuntary hospitalization, consistent with the
standards of the day.
So do I think the “old days”, with the availability of long-term inpatient
treatment for severely ill patients, were better than today’s world of
inadequate numbers of inpatient beds and ultra-brief hospitalization? The
answer is “Yes, but…” Not all long-term stays were necessary or useful.
The complexity of managing health care costs, however, is beyond the
scope of this essay. I’ll simply say that I liked it better when I didn’t have to
justify my clinical decisions to a managed-care reviewer.
One thing that I don’t think has changed much, and I think is a good thing,
is the variety that we have available in the practice of our craft. Outpatient,
inpatient, administrative, academic, research, C&L, child, adolescent, adult, geriatric, chemical dependency, forensic, psychotherapy,
psychopharmacology, procedures (ECT, TMS, Ketamine), you name it, mix
and match. Then and now it makes for an interesting life.
However it concerns me that with the “medicalization” of psychiatry we are
inadvertently providing our patients with easy answers that may be
misleading. Also, TV ads for the latest medication like the one that assures
you that “you are bigger than your bipolar disorder” make me cringe. Am I
happy that in retirement I no longer have to explain to a patient — in fifteen
minutes — that their mood instability due to complex trauma and borderline
personality will not be cured by a pill? You bet!
Perhaps I may be too cynical about the advances in psychiatric
“procedures” and “precision psychiatry”. After all, at this point I’m out of the
game and maybe not able to grasp the value in such concepts. Perhaps
I’m too wedded to the concept of trying to understand, and help a patient
understand, the complexity of biologic, psychologic, and social issues as it
relates to their distress.
In conclusion, here are a few issues that I think make contemporary life as
a psychiatrist more of a hassle than in the “old days”:
Managed Care. We didn’t have managed care breathing down our necks.
This is not to say that clinical consultation is not of value in identifying and
modifying inadequate, inappropriate, or self-serving treatments. In the old
days I did some care reviews for a start-up managed care company. As I
recall, the interventions I had were generally collaborative and useful, but I
wasn’t an inexperienced “provider” going over a checklist.
Electronic Medical Records. I’m all for having standards in
documentation, readability being one of them, but I stand with the many
doctors who are going nuts over the time that is eaten up with record-
keeping. Having to learn a different EMR when you change jobs or
your company buys a new system is an abomination. There should be
a single, standard electronic record across the nation designed by
doctors, perhaps with tweaks for different specialties (the VA has used
a standardized system for years). Problem is, this wreaks of
nationalized medicine (socialism?), and EMR’s are big business.
Direct-to-Consumer Advertising. This is an easy one — get rid of it. It’s
annoying having patients ask about the allegedly latest and greatest
medication when what they’re on, or a cheaper medication you will
prescribe, is just as good. DtC ads increase the cost of medical care
and complicate managing patient expectations. And in the meantime,
get rid of those deceptive ads for nutraceuticals that proclaim they’ll
enhance cognition, promote vitality, or make you feel younger, but have
no evidence of benefit whatsoever.
From my mouth to God’s ears...
