Addressing the shortage of psychiatrists: What keeps us from seeing more patients?

• Secretarial. No one was able to give me an estimate of how many hours per week were spent directing, managing, and training support staff, or of how many hours this freed up to see patients. One psychiatrist in a large practice noted that they have 32 full- and part-time professions, including 3 psychiatrists; they participate with insurance, and this requires 18 full-time support staff.

• Office-related issues. Rent – this is both taste and geographically driven, and there are several ways to come by office space. Other factors are time related to restocking supplies, furnishings, technological hardware, phones, faxes, pagers, mobile lines, postage, technology support, cleaning, and assorted office-related issues. I have no time estimates on this; some people have support staff who do most of it, and again, this is part of the routine practice of having a business. It takes time, but it’s not irrelevant. Also, time is spent keeping an office both OSHA and HIPAA compliant.

• Hospital/agency-related requirements:

– Risk management seminars.

– CPR training.

– Health maintenance (required TB testing and flu shot).

• Required learning modules. When I worked 4 hours a week at a hospital clinic, there were many requirements. I watched modules on how to use elevators in buildings I never entered, how to place a central line, hand-washing and infection control, and how to store chemicals I never used. I believe that Maryland state employees may be required to have training in trauma-informed-care.

• Uncompensated time returning calls/communications to patients, families, other clinicians, and prospective patients who then decide not to come in, as well as filling out paperwork for disability claims, other agencies, and writing letters for patients. While this also is part of routine medical care, several people mentioned that other professionals can bill for this work and that insurers can force unnecessary care because only face-to-face treatment gets reimbursed, so issues that might be resolved on the phone or by telepsychiatry then require an office visit.

One colleague was kind enough to examine her own full-time practice and sum up her activities. She came up with an estimate that she devoted 40 hours per month to administrative issues that divert time from seeing patients. This did not include the time she recently devoted to MOC.

Obviously, I want to make the point that part of the psychiatrist shortage is related to the fact that there are administrative demands – many that don’t improve clinical care – that decrease the number of patients we can see and increase the cost of care. In addition to the weekly toll, many of these time drains are frustrating, and serve as disincentives to seeing patients with what time is available. The statistics prove that psychiatrists are less willing than other specialists to participate with insurance networks, and I suspect the litany of clinically irrelevant requirements may lead to earlier retirement by people who might otherwise be willing to practice for more years.

One might ask, at what point do we fight back against spending our time meeting the agendas of agencies and insurers when they aren’t relevant to the care that is needed to help patients?

With thanks to Dr. Mahmood Jarhomi, Dr. Patricia Sullivan, Dr. Sue Kim, Dr. Laura Gaffney, Dr. Maria Yang, Dr. Marsden McGuire, Dr. Annette Hanson, Dr. Robert Herman, Dr. Kimberly Hogan Pesaniello, Dr. Peter Kahn, Dr. Mark Komrad, Dr. Susan Molchan, Dr. Suzy Nashed, and Dr. Rebecca Twersky-Kengmana.

Dr. Miller is coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).