I was talking with a friend the other day. I’ve known him for at least a decade, and years ago, he told me that he takes Paxil. It’s not something he’s brought up in a long time, but over the weekend, unrelated to the topic we were discussing, he suddenly said, “This med check thing is quite the racket psychiatrists have going.” He sees his psychiatrist for 15 minutes every 6 months.
“The question is always the same. He asks me, ‘On a scale of 1 to 10, rate your mood.’ I answer, but you know, in 6 hours I might have a different answer.”
I didn’t ask what the med check sessions cost, or why he doesn’t get his prescription from his primary care doctor, but I can’t imagine that the psychiatrist is making any great fortune from the two visits per year my friend (or his insurance company) pays for.
But he’s also my second friend in a matter of months who has commented to me how his brief checklist visits with a psychiatrist feel like they are more about the doc making a buck than about the well-being of the patient. The other friend saw a psychiatrist for a monthly med check to obtain a stimulant prescription at a cost of $120/visit and quickly calculated that the psychiatrist was earning $360 an hour. Is that too much or too little, or does that even matter? What does matter is that there are no warm or fuzzy feelings here.
I don’t believe that every patient needs, wants, or benefits from psychotherapy, but I do believe that treatment should be tailored to the patient – so while weekly therapy with a psychiatrist may make sense for some people and 15-minute visits twice a year may make sense for others, there isn’t a template that leaves everyone with the best care. Somehow, the insurance industry decided that reimbursement would be more lucrative for brief visits.
This translated into a paradigm where management of a psychiatric conditions could be done in 15- or 20-minute blocks, and a treatment model developed where psychiatrists limit interactions to a checklist of symptoms and side effects. Obviously, I’m not telling you anything you don’t know.
The economics may be clear, but what gets washed out is how much some patients dislike and disdain their psychiatrists and the negative backlash psychiatry has suffered in terms of the image the public has of our work. If you’re not sure about this, just look at the comment section of the online version of any article about mental health in the New York Times.
Some people feel that psychiatry is about checklists and prescriptions pads – psychiatrists are “pill pushers” (they don’t just suggest, they push), and they are angry that their doctors don’t know them, don’t care to know them, and aren’t interested in understanding their symptoms in the full context of their lives.
One of the troubling aspects of this approach to care is that even when the treatment is successful and the patients get better (as in the case of both of my friends above), they may well walk away angry or ungrateful. As much as people want to get better, they also want to feel heard.
So is it a racket? I don’t know that anyone’s motives are bad – as a “racket” might imply – and it’s clearly not the model that all (or even most) psychiatrists practice by, but for some patients, this approach to treatment is misguided, and it’s unfortunate for all of us that is the image of psychiatry that the public has come to see.
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DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press.