The practice of psychiatry has become industrialized, learning from and emulating Henry Ford's production-line methodology while borrowing a twisted version of President Roosevelt's New Deal. Features include a highly controlled environment and a mechanized system of carefully timed and impersonal clinic-patient-doctor interactions, combined with an Orwellian financial c-change, amongst others.
Some psychiatrists were trained in the old days, some in the new days. For those trained during the old days, talk therapy and knowing one's patients were the cornerstones of the practice of psychiatry. The 50-minute talk therapy hour was the rule. New-days trainees value neither, nor were they trained in it. Irrespective of training, both the old and new see the new economic light, which rules the very large majority of their practices. Not talking earns a great deal more money than talking. As The New York Times reports, a 2005 government survey found that only 11 percent of psychiatrists practice talk therapy. Talk therapy and the 50-minute hour are psychiatry's equivalent of high button shoes.
Economic New Deal: A Pill For Every Pot
Insurance companies dictate how psychiatry is practiced. For old-way practitioners, the fees that insurance companies pay for talk therapy are low and getting lower. Psychiatrists could accept less money and provide time to patients for talk therapy even when insurers do not pay sufficiently, but they rarely do. Psychiatrists have discovered, however, that medical insurance companies pay handsomely for writing prescriptions, which lures the very large majority to participate in the financial windfall.
Economic New Deal, Part 2: More Pills For More Pots
How office practices are run has changed dramatically, taking guidance from Henry Ford's production line. The office manager is the equivalent of the foreman. Most psychiatrists are, like most physicians, weak at operating the cash register, so it is the office manager's job to install and keep the psychiatrist's operation in a future- and financially-oriented mode. Office managers run the production line. They bring in and operate computers, accounting and billing systems. Unlike their employers, they haggle aggressively with insurers, who are slow in payment or reluctant about approvals. Further, in this eye-for-an-eye world, the office manager usually brings unique innovations, such as requiring that patients pay everything up front and instituting fees for missed appointments, faxing, calling, writing prescriptions, etc. Another new and probably foreman-inspired practice takes a page out of a money-earning practice utilized by most attorneys, that of billing by the minute for telephone calls to the attorney. Typical charges vary; in my area, it's usually $8 per minute to talk to the doctor. Office managers attempt to keep their doctors from becoming involved in their patients' problems, which keeps the doctor from participating fully in his or her part of the production line: writing prescriptions.
The insurance companies set the price. A psychiatrist working eight hours a day doing talk therapy earns approximately $940 a day, $4,700 a week and $225,000 per year. He or she is paid the insurance-company-set rate of $120 to 130 per hour, a seemingly handsome income. But in the new world, that's chump change.
Insurance companies' set rate is $85 to $100 dollars for a 15-minute, once-a-month, "medication management" visit. Many psychiatrists manage this feat in considerably less than 15 minutes. A typical psychiatrist's practice is largely based on the approximately 10-minute medication management session, which allows the doctor to see approximately 38 to 42 patients each day. Five additional minutes are allowed each patient for social niceties, ushering them in and out, offering them the chair and getting the next chart -- together, these add up to 15 minutes. Seeing 38 to 42 patients each day at $100 a visit comes to an approximate total of $4,000 per day. To that $4,000, one must add "special fees" (see above), averaging $30 per appointment, or $1,200 per day, raising the total income to $5,200 per day. That's $26,000 a week, roughly $104,000 a month, and $1,248,000 per year. This is a very handsome -- some think grossly obscene -- amount, definitely not chump change, and five and a half times the income of the talking psychiatrist. From a strictly economic point of view, it doesn't take an Einstein to pick the correct field. Don't talk.
A Wrench In The Cogs Of Humanity
Psychiatry, as all areas in medicine, is supposed to be a calling, not the pathway to a pot of gold. It is not meant to emulate Ford or a twisted Rooseveltian New Deal. It should not be a production line, based on greed and grossly inadequate care. I and my colleagues are meant to serve our patients, not be unreasonably served by them, if Hippocrates and common morality be valued. If a psychiatrist's goal is to make large amounts of money, utilizing the systemic flaw of writing prescriptions for powerful medicines to patients he barely knows, he should leave the field of medicine. The functioning and dysfunction of the mind, like all areas of medicine, are "we-don't-know-nearly-enough" disciplines, not "how-do-I-make-more-money?" disciplines. The "devoted-to-c-change-money" psychiatrists are a very large part of the problem and no part of the solution.
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