Book Review: Psychiatrist rejects ‘physician as cog’ model of care


The title of the book, “Passion for Patients,” by Lee H. Beecher, MD, DLFAPA, FASAM, with writer Dave Racer, MLitt (St. Paul, Minn., Alethos Press, 2017), clearly represents Dr. Beecher’s approach to his professional life: His focal interest has been his patients ever since he went to medical school and started a very long and successful practice.

Dr. Beecher’s years of practice encompass many of the changes that the practice of medicine has seen in the last 50 years.

He attended medical school when an office was the place where a physician and his patients would get together to exchange thoughts, feelings, ideas, and plans so that they would eventually work together directly and unencumbered on the same concepts that they share and that they considered crucial to their relationship.

Shortly after Dr. Beecher graduated, Medicaid and Medicare came into medical practice, together with progressive limitations, threats, and a great many unwelcome interlopers, whose mission drastically changed the doctor-patient relationship. No matter how one examines the actions of the numerous new participants – be they auditors, insurance companies, employers, or money managers – one of their main missions was to modify, qualify, re-identify, and limit the interaction between the doctor and the patient.

Dr. Rodrigo A. Muñoz

Dr. Rodrigo A. Muñoz

In one of his last actions as president of the United States, Richard M. Nixon signed the Health Maintenance Organization (HMO) Act of 1973 into law. The new law, seen as an answer to the “health care crisis of the late 1960s” , made federal assistance available to participating group practices and medical foundations that provided prepaid care (Soc Sci & Med. 1976;10:129-42). Dr. Beecher sees HMOs as a major source of limitation, if not strangulation, of medical care. From the 2017 vantage point, many years after the introduction of HMOs, we can easily examine the results on medical practice: psychotherapy has been practically eliminated in psychiatric practice, follow-up visits have been reduced to 15 minutes, and the richness of the doctor-patient relationship has been diminished – to the point of extinction in many places.

“What is amazing – and contrary to truth – about the current evolution of medical care reform is its manifold references to safeguarding the best interests of the patient,” Dr. Beecher wrote. “On the contrary, the medical care reformers in current vogue see the physician as but one cog in the production of a specified medical care outcome – a cog that must be greased by evidence-based medicine and managed by analytical applications derived from data, cured in the crucible of number crunching, and controlled by payment systems.”

We live in an age when forces other than medical thinking and practice are trying to define what psychiatrists do, how we do it, and whether our effort is worth being paid for. This has created lack of satisfaction in the exercise of psychiatry, early retirements, and lack of growth in many quarters. When one considers that practically all psychiatric endeavors can be traced to the efforts of devoted practitioners interested in improving the profession, one can see that the future might look bleak because people other than psychiatrists define, quantify, and evaluate the practice of our specialty.

For Dr. Beecher, the best way to provide individualized care to patients was to restructure his practice.

“I escaped from managed care into the practice model that had served so well for decades prior to HMOs, [preferred provider organizations], and other externally controlled practice models,” he wrote. “My patients paid me directly.”

Dr. Beecher is a witness and protester, as well as a thinking innovator, coming to defend patients and physicians at a time when they are under attack from precisely the same forces that were supposed to help and support them.

Throughout his book, Dr. Beecher tells us the story of his many points of disagreement with the intruders and his many arguments in favor of patients and doctors, going back to the beginning of the forces that are controlling and destroying their relationship at this time and advocating principled resistance and a careful search for independence. The reader easily accompanies the author to the points when independence blends with excellence – accepting that neither one exists without the other.

Dr. Muñoz, a former president of the American Psychiatric Association, has written eight books and more than 200 articles about various aspects of psychiatry. He is a professor of psychiatry at the University of California, San Diego, and has a private practice. Dr. Muñoz and Dr. Beecher serve on the Editorial Advisory Board of Clinical Psychiatry News.

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