Self-Justification About Conflicts of Interest

Some amount of self-interest is inevitable; we all need to make a living. At the same time, the high cost of health care makes society question the altruism of physicians. We know that psychiatrists receive a tiny slice of the health care budget pie, and we may have some degree of envy for those in more lucrative specialties. Of the 27 medical specialties surveyed in the 2017 Medscape Physician Compensation Survey, psychiatry is in the bottom quartile of earners, just above pediatrics, family medicine, endocrinology, internal medicine, and infectious disease, and equal to rheumatology. Meanwhile, orthopedics, plastic surgery, urology, and cardiology make about twice what we do. Add to the mix the burden of paying off student loans and funding our children’s education, and the altruism that inspired us to choose psychiatry may be overshadowed by other motivations.

Although we want to think of ourselves as patient-centered and compassionate, it is easy to stray from that noble path. The soprano inner voices of discernment and virtue are drowned out by the bass voices of self-interest and greed. In the last six months, I have heard from patients and colleagues about three ways in which psychiatrists may increase their revenue by justifying the need for additional clinical services.

The first of these I learned from an elderly patient transferring her care from another psychiatrist because she didn’t like the office requirement that she provide a urine sample for a toxicology screen at every visit. This patient had no history of substance abuse. She could understand why the doctor might want to test his patients at all initial visits, but repeated testing seemed clinically unnecessary to her. She felt that either he didn’t know her as an individual with a specific history or he didn’t trust her. In turn, she didn’t trust him. Perhaps, like me, she suspected that this in-office testing was an additional revenue stream for the psychiatrist.

Another transferring patient specifically asked me about my policy for late arrivals to appointments. His previous psychiatrist would not see people who showed up 10 minutes late for appointments and would charge them for the missed session. This policy is understandable in the context of a busy mental health center or hospital-based clinic, where providers have 15 minutes to see a patient and write a note; one late patient can throw off the entire day’s schedule. It’s more difficult to understand in a private-practice setting. My patients know that they have reserved a specific interval of time with me, they are paying for it, and they are entitled to as much as their late arrival allows. If they are 15 minutes late for a 20-minute medication monitoring appointment, they understand that we will be rushed and may have to schedule a second appointment if a significant medication change is indicated.

On two separate occasions with colleagues, in the setting of case conferences, they declared that they strongly encouraged all of their patients to see them twice a week for psychotherapy. If there was an abundance of psychiatrists so that patients would feel free to move to another provider if they don’t want twice weekly therapy, the policy would select for patients who want intensive psychotherapy. However, in Colorado and throughout most of the country, there is a shortage of psychiatrists, and few who are accepting new patients. Patients who are desperate for help and have sufficient resources may feel somewhat coerced to comply with the psychiatrist’s recommendation, even if it’s not really what they want or need.

While ordering routine in-office labs, creating strict policies about late arrivals, and scheduling frequent visits may all seem like justifiable actions when seen from a business perspective, they have the potential to harm the patient-psychiatrist relationship. When a psychiatrists’ actions are based on what is expedient for the practice, they may inadvertently be a betrayal of the patient. Our foremost duty is to our patients. Considering the many rewards we glean in our profession, it behooves us to guard against the appearance of ingratitude or greed, and redouble our commitment to putting patients first. ■