I very much resented the splitting of therapy between the doctor and the nonphysician. Now I am surrounded by master-level psychologists and social workers (MSWs) whose practices are burgeoning. I am also told by many graduating residents that they are being hired by other personnel, psychiatrists, MSWs, and so on, into their practices. How does the primary care physician fit into this mix?
I can hear the telephone conversation now. The primary care physician calls up and says, "I have a patient I’d like to bring over for you to see." The psychiatrist says, "I can’t now. I’m seeing a patient." The primary care physician says, "Thanks. I’ll call Jim. I’m free now, and want to come over and sit with you to see if my diagnosis is correct. Goodbye." Suddenly, you’ve got a new partner, but his name is not on the door.
All the specialties in psychiatry could complicate the process further. Some psychiatrists might be uncomfortable saying to the primary care physician, "I don’t know much about geriatric psychiatry, so you take care of the elderly person." We could then turn over to primary care, other specialties such as addiction psychiatry. Where would it end?
Of course, there is a shortage of psychiatrists. And we do need to figure out how to expand the work force, perhaps with more residency slots. We could use an injection of funds from the federal government, like we got in 1969-1970. This injection enabled us to expand academic programs and make them better.
Finally, I am worried that this new diagnostic manual will encourage a greater use of psychotropics for a field that in 50 years has converted from 100% psychotherapy to one dominated by medications. Primary care physicians believe it’s their duty to give the patient a prescription at the end of each visit. These developments could mark the sad end of our proud profession.
I recently had a high fever and went to the emergency department. The first thing they did was to give me intravenous antibiotics. In the meantime, I spent 3 days in the hospital. The antibiotics did their work without me or my doctor having any idea why I got such a high fever. We never did find out the possible source of the infection.
Similarly, in our psychiatric EDs, if a patient comes in and says he’s hearing voices, he gets a shot of risperidone. By the time he is transported to another part of the hospital, the entire diagnostic process has been destroyed. The jump to medicines in general medicine and psychiatry is not good.
So, I am clearly opposed to the preparation and sale of this book. It could do more harm than good.
Dr. Fink is a psychiatrist and consultant in Philadelphia and professor of psychiatry at Temple University. He can be reached at cpnews@frontlinemedcom.com. This column, "Fink! Still at Large," appears regularly in Clinical Psychiatry News.