Better System for Future?

This communication was stimulated by the headline on page 2 of the May 17 issue: “Angry Response Follows Appointment of Psychologist to Head Yale Center.”

As I look back on my decades in medical education, I recall medical school quotas for women, African Americans, and Jews. After correcting those, a historical relic was that to do psychotherapy in the United States, one had to be a licensed physician. There were a few exceptions, such as distinguished products of European psychoanalytic education, which credentialed nonphysicians. The only other exceptions were psychologists who conducted testing and social workers who were employed by clinics and a handful of enterprising physicians for what was called casework. It was not uncommon that those professionals performed psychotherapy under the supervision of the physician.

This was the era when intravenous punctures had to be done by physicians; nurses not permitted. Hence, if an intravenous needle got out of vein in the wee hours of the morning, the intern had to be awakened to reinsert it. (I won’t burden you here with my grateful stories of experienced, thoughtful nurses who made a deal with me that they would let me sleep and reintroduce dislodged needles providing I took responsibility if complications ensued.)

Change began in the 1960s with the report of the Joint Commission on Mental Illness and Health, which had been created by Congress and encompassed 36 organizations. The process of change was slow in evolving eventually to where the landscape is littered with nonphysician psychotherapists. Indeed, psychiatry residencies debate whether and the extent to which residents should have learning experience in psychotherapy.

I predict that eventually the inherent irrationality of today’s medical-education hierarchical systems at various levels of expertise will be replaced by interlocking systems of permeable hierarchies of competence and certification.