The Life and Death of Psychiatry

The Doctor-Patient Relationship in Some Managed Care Systems

by T. J. Glenn, M.D., F.A.A.C.A.P.

Introduction

There is a legend about the Phoenix, a fabulous bird, who after a long life immolates (sacrifices) itself on a pyre and rises from the ashes to begin a new cycle of life. The symbolic "Traditional Psychiatry Phoenix" may be about to be sacrificed!

As members of the medical field, we must be aware that all of medicine and psychiatry in particular is subject to the Phoenix Phenomenon. In order to survive the pyre of greed, politics, the economic ethics of managed care, and the psychiatric services provided by lesser-trained persons, who may or may not be state certified to do so, we must be ethically concerned and politically active to maintain the highest quality of psychiatric evaluation and treatment of our patients.

Psychiatry may be a vanishing specialty of medicine and we, as members of the medical profession, must inform the public, the state and federal legislators, and our representatives in the national and regional psychiatric associations about the on-going turf battle between medical and non-medical providers for control of the mental health money and standard of mental health services.

We must remember that psychiatrists are trained physicians who evaluate and treat the whole person's mental illness, including how other illnesses can affect that person's mental state. This must be done with continuity of care for the whole person. Managed care systems tend to limit the psychiatrist's role to prescribing psychotropic medicines from their formulary and may request the psychiatrist to sign off on limited psychiatric evaluations and treatments performed by lesser-trained mental health professionals.

Interdisciplinary Treatment Teams

Future dilution of the quality of psychiatric care is being achieved by elimination of interdisciplinary treatment teams. Many times former psychologists and counselors are renamed "case managers" or "coordinators of services." They are given unrealistic caseloads, which forces them to act as a triage person without time or permission to become involved in a patient's treatment.

In managed care systems the former medical model is redefined as a market economy-market and the patients are called customers, consumers, or recipients in need of mental health services. The mental health providers become aware of their need for a market share of consumers.

As members of the medical profession we must help others be aware of psychiatry's quality standard of care for mental illness and protect the patient's right to know the level of training of mental health providers so they can make an informed choice for their mental health treatment.

House Bill 1467 and Communicating With Legislators

A proposed Licensed Professional Counselor Bill (House Bill 1467) would have allowed licensed professional counselors (LPCs) to diagnose and treat mental and emotional disorders, including the rendering of psychotherapy and in-hospital treatment of patients. According to the Missouri State Medical Association Legislative Report dated February 17, 2000, the Missouri State Medical Association testified in opposition to this bill. MSMA suggested that LPCs do not have the training and education necessary to make a medical diagnosis and that anyone ill enough to be hospitalized probably should be under the care of a physician. This proposed bill died in committee for now.

Our concerns need to be communicated to our County Medical Society legislative representatives and to our state and federal legislators. Physicians seem to have been pressured into approving lesser-trained medical helpers to practice patient care functions in order to expand the number of patients who can receive care for their medical needs.

This allows managed care systems to deliver mental health services using an expeditious assembly-line approach resulting in high volume and lower quality of care. In the past these helpers were allegedly under the direct supervision of the physician. Many of these former helpers have become paraprofessionals and have assumed their own autonomy. Many have created their own specialty and have become state certified professionals. They compete for their market share of customers needing medical-mental health services.

Quality Care from a Historical Viewpoint

Historically one way of maintaining quality of care was by integrating the paraprofessional's medical and mental health services. This was accomplished by having a shared Therapeutic Treatment Team approach to patient evaluation and treatment with supervision by the physician. This is still taught in theory at the University level but in the real world of delivery of patient care there seems to be a revolt against anyone wanting to be supervised.

Today's Professional Challenges

We live in a time of entitlement, permissiveness, and resistance to any form of supervision. I am reminded of a course in child psychiatry several years ago. The title of the lesson was "Equalitarianism versus Authoritarianism (Fascism)." The message was that there was a revolution going on in the world between those in charge and the ones being managed.

The physicians are no longer held in high esteem as the person in charge. In many sites the Therapeutic Treatment Team is not permitted to meet and discuss patient care needs.

Today the delivery of mental health services is so fragmented that it is almost impossible to know who is responsible for the total care of the patient. A common practice is to sue the doctor and hospital if malpractice is charged for services rendered in the Psychiatrist's office or in the hospital. Perhaps the unsupervised providers of mental health services may be held libel for malpractice charges and the physician will only be held responsible for diagnosis and specific treatments including medicine and procedures performed only by him. This will have to be tested in court.

I feel it is imperative that the psychiatrist or the assigned physician be responsible for the over-all care of the patient. This seems to be in direct opposition to having multiple providers with no supervision or integration of total patient care. As members of a medical team we must never sign off on any psychiatric care, which we do not provide or supervise. Our professional service and signature is important to the well being of all people.

Where Should We As Professionals Focus?

The Renaissance of the renewed Psychiatrist's Phoenix phenomenon needs to focus on the mission to provide comprehensive quality Psychiatric Standard of Care regarding the diagnosis and treatment of the patient's Mental Illness. The goal must be to emphasis medical--excellence, maintain professional creditability, continuity of care and preserve the dignity of the patient in the process.

This site is a supplement, not a substitute, for professional help.

T. J. Glenn, M.D., F.A.P.A., F.A.A.C.A.P.
20450 Huebner Rd.#203
San Antonio TX 78258
Fax - 210-495-5436