Trustees Act on AAMC Brief in Harvard Case, Multiple Other Issues

Psychiatrists “need to look internally at who we are, what our identity as psychiatrists is, and what our aspirational goals are,” said Robert Trestman, M.D., Ph.D., chair of APA’s Council on Healthcare Systems and Financing, in a report to the APA Board of Trustees in July.

Trestman recounted the well-known problems of lack of access and the familiar culprits: poor reimbursement; administrative hurdles and barriers; inadequate infrastructure investment; and longstanding stigma against mental illness, substance use, and psychiatry as a field.

But Trestman suggested that psychiatry, as a profession, needs to hold itself to account as well. “What makes us different from others providing care to people dealing with mental illness and substance use disorders? We typically assert that our training is the difference. Four years in medical school, training in neuroscience, four years in residency, and—for many—additional years in fellowships. We assert that gives us unique skills in differential diagnostics, differential therapeutics, management of medical comorbidity, and severe illness management.

“Compared with the other [mental health] disciplines, this is extraordinary,” he said. “And then we undercut ourselves by often choosing to treat people who quite reasonably might be cared for by those with far less training: patients with uncomplicated mood or anxiety disorders, moderate severity personality disorders, or subsyndromal disorders.”

Trestman said psychiatrists abdicate their medical training by not coordinating medical care of straightforward and common conditions such as noninsulin-dependent diabetes, hypertension, and hyperlipidemia. “And many of us choose to opt out of insurance reimbursement and accept only cash payments from the financially secure patients,” he said.

“There are many justifications for focusing on higher functioning patients: our own autonomy and income; the satisfaction of working with high functioning, cognitively sophisticated patients; conducting psychotherapy at our own pace and using our own protocols; avoiding the complexity and challenge of hospitalizing acutely ill patients; and the real-world difficulty of finding community resources for those with social inequities. Indeed, this approach appeals to many of us: A best-guess estimate is that over 30% of all psychiatrists choose to opt out of insurance, Medicaid, and/or Medicare.”

But Trestman said there’s a problem with that: Those with less training can do much of that work.

He concluded: “As leaders of APA, here is our challenge: How are we going to address the future of psychiatry and psychiatrists? How do we justify those years of training—and federal investment in our residency training? If we do not reimagine it, others will do it for us.”