As explored in a post last week, the practice of medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but new the transition can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry, as noted in this New York Times article.

The Times article highlights the practice of Dr. Donald Levin of Doyletown, Pennsylvania.  Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

Brief consultations have become common in psychiatry, said Dr. Steven S. Sharfstein, a former president of the American Psychiatric Association and the president and chief executive of Sheppard Pratt Health System, Maryland’s largest behavioral health system.

“It’s a practice that’s very reminiscent of primary care,” Dr. Sharfstein said. “They check up on people; they pull out the prescription pad; they order tests.” The switch from talk therapy to medications has swept psychiatric practices and hospitals.

Points to ponder and background for the transition:

• Specifically, a 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since.
• Insurance company reimbursement rates and policies frequently discourage talk therapy.
• A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.
• Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so frequently begin their practice with less education-related debt — is a reason that talk therapy is priced at a lower rate. There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.

And the effect on the patients?

• Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago.

And are 15-minute sessions adequate for evaluating how well medications are working?  “I’m good at it,” Dr. Levin noted, “but there’s not a lot to master in medications. It’s like 2001: A Space Odyssey, where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.” Read more…