- Machiavelli's Laboratory is a free ebook that I published on April 13, 2010. It is a satiric discourse on scientific ethics, from the perspective of an unethical scientist. Please don't take any of the advice and opinions in the book (or the excerpts featured in this blog) seriously.
This blog entry continue's yesterday's blog, "Medicine: fast care and slow care".
Psychiatry is the quintessential slow care specialty. They sit for long sessions, listening to patients talk about their relationships with fathers, mothers, spouses, children. In the time that a psychiatrist devotes to a tedious tale of a disappointing childhood birthday party, a dermatologist could have fattened four pairs of lips with collagen injections.
There is a limit to the amount of money a psychiatrist can charge for a procedure-free hour filled with angst, regret and guilt.
By all rights, psychiatrists should be teetering on the verge of extinction. Surprisingly, psychiatry is a thriving field! The percentage of graduating medical schools who choose psychiatry for a career seems to be increasing (1). There is a growing demand for psychiatrists, particularly in the sub-specialty of childhood and adolescent care (2).
How do they do it?
Well, the most important trend has been the migration of psychiatry from the analyst's couch to the drugstore. Psychoanalysis has been widely abandoned by contemporary psychiatrists. The history of psychiatry has been revised, and Freud is currently relegated the role of "philosopher" (not physician). Today, the works of Sigmund Freud are read with greater interest by English literature majors than by medical students.
Basically, a "slow care" method, such as psychoanalysis, cannot meet the payroll of a modern psychiatric practice.
Today, there is a pharmaceutical treatment [distinguish treatment from cure] for the common mental aberrations: depression, anxiety, bipolar disorders, schizophrenia, obsessive-compulsive disorder. Proximate causes of disturbed behavior, such as suicide, phobias, and physical aggression, are triggered by one or more of these drug-sensitive common disorders. Nowadays, psychiatry is virtually a sub-field of pharmacology.
No longer is it necessary to listen to the same patient drone on week after week, year after year. It never helped the patient much, in any case. Freud and his coterie of psychoanalysts sought to provide patients with self-awareness. If self-awareness led to a cure, all well and good. But a cure was too simple a goal for Freud. Freud's detractors, of whom there are many, doubt that Freud cured anyone.
Drugs simplify and abbreviate the practice of psychiatry. Psychiatrists need not waste their valuable time on physical examinations. Patient and doctor will readily concede that there is nothing like a rectal exam to undermine a mutual sense of trust. Today, office visits are short and can often be consigned to the time taken to write a prescription.
The existentional challenge for modern-day psychiatrists is: "How can I make money off of writing prescriptions, when the drug revenues flow to the pharmaceutical companies?"
In the next blog, we'll discuss the answer.
REFERENCES
1. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by U.S. medical students. JAMA 290:1173-1178, 2003.
2. The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions, December 2008.
- © 2010 Jules Berman
key words: medical-industrial complex, American healthcare, physician reimbursement
