Managed Care and Psychiatric Training

I am a trainee of the managed care era. When I was a medical student on our psychiatry inpatient unit, staff were complaining about lengths of stay being reduced to a couple of weeks. By the time I was a PGY-2, it could be a battle for six days. Talk about insurance approvals and “doc to docs” was suddenly permeating the inpatient milieu. Sensitive and thoughtful attendings were engaged in lengthy telephone reviews; I watched their faces redden, heard their voices tighten as the calls went on.

As an eager-to-please young psychiatrist, I remember feeling gratified by compliments from the nursing supervisor: I really knew how to “manage” my cases. I could be counted on to get them “out the door.” But I also recall the niggling sense that these were not necessarily the qualities I aspired to as a psychiatrist. And I will never forget the profound sense of loss and betrayal voiced by so many of my supervisors, who emphasized that under managed care, psychiatry had become something quite different from what they had originally signed on for.

In her new book, Of Two Minds: The Growing Disorder in American Psychiatry, an anthropologist’s look at the psychodynamic/biologic split within psychiatry, Tanya Luhrmann eloquently delineates the despair of a generation of psychiatrists in the face of the managed care onslaught.

She looks, too, at the effect of managed care on training. In particular, she examines how under the influence of a managed care mindset, biological formulations and interventions assume greater authority, and “psychotherapy begins to appear less effective, less necessary, more wasteful.” As a result, psychotherapy training becomes compromised.

To me the critical issue is this: What valuable elements of training do psychiatry residents not get now that they used to get in a non-managed-care setting? Psychotherapy training, yes, but that is part of a larger problem: time. It takes time to learn clinical skills from patients and from supervisors, to listen to patients’ stories, to hear the wisdom of experience.

And time is the commodity perhaps least available under managed care. Supervisors’ precious time is increasingly spent on paperwork and phone calls; they are tired and stressed, and unreimbursed teaching time is another demand. Inpatient stays are brief. Outpatient psychotherapies are often limited to short term or are suddenly truncated by contract nonrenewals or shifts to staff-only coverage. More time in the ER is spent on finding beds and getting preauthorization numbers; less time is spent on careful assessment.

The problem becomes exaggerated in work with children. There is no way to “speed up” a play therapy or an alliance with a family. Children move at their own pace and have an intuitive sense of when they are being rushed or superficially appraised or treated as if the system really doesn’t care.

Yet in this world of cell phones, fax machines, and e-mail, the doctor-patient relationship is increasingly expected to fit the managed care model of efficiency. I fear it is a false efficiency. I fear I may be part of a generation of excellent managers, but poor listeners; treatment-plan experts, but therapy automatons; at worst, triage queens in an emergency room, but sloppy judges of the subtle signs portending crisis in an outpatient office.

Against all this I juxtapose a deep conviction that residents must feel more comfortable understanding and assessing systems of care.

The harsh reality is that mental health resources are limited, and the population is growing. Some form of health care delivery system will “manage” care way into the future. The resident who views these terms as a foreign language risks floundering once launched into practice.

In their excellent article, “Psychiatric Residency Training, Managed Care, and Contemporary Clinical Practice” in the August 2000 issue of Psychiatric Services, Drs. Michael Hoge, Selby Jacobs, and Richard Belitsky push for change in psychiatry training programs. To prepare residents for the real world, they say, programs must include more experience in different treatment modalities and more teaching on how to critically assess various health care systems, both traditional and managed. They suggest a number of practical measures to promote this goal, including a wide range of therapeutic settings like partial hospitalization and day treatment programs, so that trainees can follow patients as they “step down” through the system. And, very importantly, they underscore the importance of instilling values to “help ground a resident and provide a reference point for evaluating changes in the field.” (In my adult training, for example, the cost of psychotherapy was covered by the department if necessary to ensure residents had training in providing long-term treatments; thus, the departmental values came through loud and clear.)

I applaud these recommendations and agree that we must mourn our losses and move on. But I offer a cautionary note drawing from my work in child psychiatry with parents and families: Parents, like supervisors, teach children mostly by what they do, not by what they say. For us to produce a generation of thoughtful, careful, clinically astute, cost-attentive, and systems-savvy psychiatrists, we must first provide a generation of supervisors to model for them. Finding such supervisors and ensuring they have enough time to teach is a crucial challenge facing the field. ▪