As a solo-practice psychiatrist, I am more connected to the cost/value equation of my services than the typical system-employed physician. I’ve also written in prior posts about my concerns with modern psychiatry. I have worked in a variety of settings over the course of my career, and I realize that coming to an understanding of something as complicated as another person’s subjective life experience is a very difficult endeavor. At the very least, such an understanding takes time. It also takes a willingness to maintain the constant recognition that my perception may be wrong, and may be the result of my own bias. Finally, it takes a certain amount of intelligence. Over time, certain patterns of thought become apparent and easier to recognize– but these patterns are extremely complex, and trying to provide insight into such patterns, without causing a person to take offense, requires intelligence, patience, and tact.
I have come to the realization (a somewhat surprising realization, frankly) that psychiatry works, when practiced properly. I’ve come to realize that the ten-minute med check is worse than worthless, as a ten-minute glimpse of a person’s day is more likely to lead to the prescribing of a harmful medication than a helpful one.
On the other hand, if one has the time to sit and share small talk, then review the important issues occurring in a person’s life, and then discuss the problematic symptoms that the patient is experiencing…. then ask questions that provide context for the symptoms, and perhaps make a small suggestion or two in order to provide outside insight into the cause of the symptoms…then present the different medications sometimes used for the person’s symptoms, after first discussing whether the person would prefer medication over working on the problem through more ‘mindful’ approaches… then discuss the different side effects possible with each medication, and the likelihood that the medication chosen would be helpful…
If one does all of these things, psychiatry can actually lead to profound improvement in a person’s symptoms.
I thought about this situation recently, after paying over $500– my deductible– to repair my car, after hitting a deer. The cost had to be paid, and I found the money and paid it. I’m not a ‘rich doctor’ for reasons that I’ve discussed elsewhere, so the expense was significant– but I need a car, and it had to be paid. Likewise, I had to come up with $3000 to repair my septic tank this spring, since the alternative– having disgusting liquid bubble out of my lawn– was not an option. I had to pay my speeding ticket– I’m trying to slow down now, by the way– and I had to pay for my own health problems.
If I need surgery, the cost will likely run in the tens of thousands of dollars. Heck, having a couple warts removed ten years ago cost $400, and the doc was in the room for about 5 minutes. My auto repair bill, paid graciously by my insurer, amounted to $11,000.
Then there is the cost of psychiatric care. For reasons I alluded to in the first paragraph, I have rejected the insurer’s model of psychiatric care– the 4-6 patient-per-hour, 10-minute med check. I spend 90 minutes on the first appointment– often more. And follow–up appointments last at minimum 30 minutes, and for more complicated cases, 60 minutes. Because I see only a third as many patients, I do not accept the dramatic discounted fee offered by insurers, and patients are required to pay something.
For patients with a deductible, their cost is essentially the same as for an in-network doctor. For others, insurers pay some portion of my fee, and for some, insurers pay nothing, leaving the burden of the full cost of an appointment– $199– on the patient. For that $199, the patient receives 30 minutes of my attention, based on an education that cost me over $100,000 (not counting college), and 16 years of my life to complete– not counting grad school.
I see people who are truly suffering; people with significant anxiety, depression, addictions, phobias– problems that cause much greater disability than would a torn ACL. So here (finally) is my question. Why is it that people will roll their eyes and pay their $2000 deductible for the torn ACL, as their insurer pays $20,000 more, yet refuse to spend anything to treat their depression? Given the effect of social anxiety on a career, why will people pay $3000 for a septic tank, yet consider $400 unreasonable if spent to improve their ability to interact with others?
We all know the importance and value of a close relationship with a friend or spouse; we all fear being alone at the end of our lives. So why do we consider a $1000 plasma TV a ‘steal’, yet consider the same amount, if spent to solidify a marriage, a huge expense?
There is so much good that psychiatry can do. But I am not impressed by the value of fast diagnoses, and rapid-fire medications. On the other hand, a limited series of visits, to treat targeted symptoms, can be one of the most cost-effective areas in medicine. I often think to myself, ‘I can FIX this person’s problem– but not in 30 minutes!’ I’ll be frustrated that a person does not consider treating their psychiatric symptoms as valuable as purchasing a new car, or a larger house. Gosh– my entire cost of treatment– enough for plenty of visits– can be covered by ONE monthly mortgage payment. And while the mortgage bills keep coming, the benefits of treating one’s symptoms can become a gift that keeps giving, month after month and year after year.