Principles for freshly minted psychiatrists

Dr. Nasrallah responds

I thank my 5 colleagues for their perspectives on my editorial. You all made cogent points.

I agree with Dr. Israel that our patients’ records are now accessible by many entities due to the drastic changes in our health care delivery system. However, while I regard the basic psychiatric signs and symptoms as medical data, like heart disease or cancer, there are personal details that emerge during psychotherapy that should remain confidential and not be included in the written record, and thus are not accessible to billers, health insurance companies, or malpractice lawyers. As for physicians who consider suicide because of fear of the consequences of receiving psychiatric treatment that becomes a matter of record, that is a matter of the unfortunate stigma and ignorance about mental illness and how treatable it can be.

Regarding Dr. Cash’s comments, I agree that psychiatrists should be (and are almost always are) introspective about their vulnerabilities and limitations, and should act accordingly, which includes taking care of their needs to stay healthy and avoid burnout.

As Dr. Beecher pointed out, the employment model for psychiatrists does have many implications and constraints for patient care. I concur that having a small direct-care practice, sometimes called a “cash practice,” provides patients who can afford it the complete privacy they desire, with no one having access to their medical records except for their psychiatrist. Your book is a useful resource in that regard.

Dr. Kasturi is right about the importance of arriving at an accurate diagnosis before embarking on treatment; otherwise, patients will suffer from “therapeutic misadventures.” I have observed this being experienced by some of the patients referred to me because of “treatment resistance.”

Thanks again to my colleagues for their comments and suggestions to the newly minted psychiatrists for whom my editorial was intended.

Henry A. Nasrallah, MD
The Sydney W. Souers Endowed ChairProfessor and Chairman
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri