Retraining the Practicing Psychiatrist

When the British psychoanalyst Michael Balint (1) was asked what was necessary in order to train medical physicians to do psychotherapy, he replied, "a limited, though considerable, change in the doctor's personality." We are now challenged to bring about such a limited, though considerable, change in personality in ourselves if our specialty is to thrive in the coming years. We have lost time, ground, and credibility in what Fink (2) called "holding the line" and what Michels (3) referred to as "psychiatry's resistance to managed care." We have chosen to oppose the messenger while ignoring the message.

The debate requires reframing. The question is not whether psychiatrists should reconfigure their work practices to fit with employment in publicly traded corporations, but whether we are willing to adapt to a changing environment and develop the skills and attitudes that society is telling us it requires.

The academic health centerand managed care

If practicing psychiatrists are to adapt, mechanisms must be found to structure the process. One suggestion is that the academic health center be used to spearhead change. This solution is problematic, as academic health centers have themselves lagged in adapting to managed care, partly because of physicians' attitudes. A recent survey of medical school faculty and students traced trainees' negative feelings about managed care to their teachers, referring to the transmission of cultural barriers as a "hidden curriculum" (4). Although some might contend that such barriers represent the triumph of ethical principles over venality, the sweeping nature of opposition to managed care in academic health centers and the general community suggests a failure to separate the principles from the purveyors.

Van Dyke and Schlesinger (5) have argued that if the academic health center is to help bring about the necessary transition in psychiatric practice patterns, it must first change itself: the trainers must be trained. The authors compare this situation to corporate reengineering, which requires cultural change. For example, the development of expertise in time-efficient treatment requires accepting the optimal endpoint of therapy as functional integrity, not cure.

Shore (6) considered the core needs of contemporary practitioners to be skill in focused treatment, awareness of cost and administrative issues such as quality improvement, utilization management, and best-practice paradigms; sophistication about risk management; and sensitivity to medical ethics. In a survey of academic health centers, he found that very few took the responsibility of working with community practitioners in developing such competencies.

Models for reengineering academic health centers exist, but their viability remains to be determined. Wetzler and coworkers (7) have described an initiative at a New York academic health center in which a department of psychiatry assumed the dual roles of manager and care provider, offering administrative and clinical services to populations of patients on a full-risk capitation basis. Although the program was regarded as a success during its first year, it may be too early to determine its ultimate fate. The authors identified the key requirement as cultural change: "The department's strategy to pursue risk-bearing contracts meant a complete transformation in our organization and legal structure, and in the mind-set of our practitioners."

The changes in mind-set included a shift from treatment geared toward individual patients to the care of populations. The guiding principles included treatment based on medical necessity with the goal of return to function; parsimony of intervention; problem-driven treatment with close attention to the timing of presentations (why now?); and "good enough" care, defined as symptom remission and relapse prevention. Staff became sensitized to the financial constraints of a limited budget. They also became flexible in their scheduling and practice patterns, following patients as they moved from one setting or level of care to another; more collaborative with family and other practitioners; and more reliant on patient education. In doing so, they also became a group practice.

Meyer and Sotsky (8) called for restructuring psychiatric residency curricula to better prepare trainees for practice in managed systems. One program that has done so is the Dartmouth-Hitchcock Medical Center, where the knowledge base and skill set reflect values drawn from the British system— the firm model, in which residents follow their patients longitudinally across venues of care rather than through fixed clinical rotations as in American programs. According to Meyer (9), the reeducation of practicing psychiatrists to function successfully in managed care has become a departmental priority.

The features described in these articles are familiar elements of managed mental health systems, rooted in community and military psychiatry and staff model health maintenance organizations and described repeatedly in the literature over the past 30 years. They represent attitudes and strategies appropriate to the care of populations. It has been suggested that they offer a model of what psychiatrists of the future should know how to do (10).

Responding to the challenge

At the systems level, we must address the task of redefining the nature of our specialty by reconciling advances in molecular biology, genetics, epidemiology, and the cognitive sciences with our understanding of individual and group psychology. Detre and McDonald (11) have suggested that such unity might be achieved by merging psychiatry with neurology. Gabbard (12) has urged that treatment of brain and mind be better integrated, but not at the cost of abandoning traditional roles and functions.

The psychiatrist of the future will personify such integration by functioning as a consultant to mental health and other professionals, leading the team that treats the most complex patients, and guiding the care of people whose problems place them at the boundaries of medical, addictive, and mental illness. The practice of psychotherapy by psychiatrists should probably be limited to patients requiring both a psychiatrist and psychotherapy. Recent reports from the American Psychiatric Association practice network support these predictions (13).

Organized psychiatry's opposition to managed care has been generic and shortsighted. While supporting parity legislation, psychiatry's leaders oddly overlook the fact that an expansion of managed care will follow. Because the crucial variable in managing care is the need to change clinicians' behavior, parity will highlight this issue. The mandate to change will require more than compliance from practicing psychiatrists; it will require new learning. Academic health centers should become players in promoting such learning.

A proposal for retraining

Continuing medical education (CME), the mechanism designed to address the gap between what practitioners know and what advances in the field require them to know, has failed both as a concept and as a regulatory device. Can anyone seriously contend that CME requirements are attuned to gaps in knowledge, or that the average practitioner's behavior is reshaped by meeting these requirements? Information, though readily available, is not by itself an agent of change. Although economic forces are slowly forcing cultural change, no formal mechanisms exist for "retooling." Retooling among the adult workforce has become common in other fields, where many have returned to graduate or even undergraduate settings to learn new skills. How might such retooling work in psychiatry?

To date, mental health organizations seeking to promote change in clinicians' behavior have relied on consultants and training workshops— a new industry spawned by CME dollars, offering attractive samplers. One-shot instruction or organizational consultation of this type will not change behavior, because it occurs out of context, discontinuously, and through extrinsic rather than intrinsic means. Furthermore, it should be clear that what is at issue here is not adding skills but effecting personal and cultural change. By default, the managed behavioral health organization has become the agent of change, and resistance to necessary change has thereby been made heroic.

A two-step process is required. First, consciousness must be raised about gaps in practice performance. The principles of quality improvement, starting with assessment measured against benchmarks, offer a model for alerting practitioners to gaps in performance and the need for correction. Rather than written exams, on-site practice audits such as those developed by the National Committee for Quality Assurance and the Joint Commission on Accreditation of Healthcare Organizations should be considered. They could be conducted periodically and could be streamlined— for example, by using electronic chart review. Although voluntary participation would be desirable, this type of approach would have to be tied to relicensure to be effective. As with quality improvement measures, verification would be necessary to gauge change.

Second, gaps in practice performance would mandate retraining, which should take place primarily within the context of the provider's own practice, supported by the academic health center. A series of case-based seminars might initially be used to engage the practitioner in creating a positive vision of population-based care. Cases would illustrate common dilemmas in service allocation, treatment resistance, ethical choices, managing risk, and treating complex disorders. Reading material would be available at Web sites, and video access would be provided to training programs already in place, on quality improvement, utilization management, focused treatment, psychopharmacology, health care financing, use of the Internet, and so on. Extended follow-up would be provided through peer supervision and assignment of a mentor, who would provide necessary consultation as the learner experimented in his or her practice. For those whose practice requires more extensive retooling, a part-time advanced-practice residency might be considered.

The introduction of accountability into professional education at the level of clinical practice would amount to a cultural shift that acknowledged the rapid pace of advances in our profession and the pressure on practitioners to adapt to new roles and functions. This shift would compel the CME industry to move in the direction of longitudinal, hands-on teaching with specific, measured behavioral outcomes in mind. Learning, a core value of our profession, would thereby become a continuous commitment. Changing the behavior of physicians has been compared to the difficulty of moving a cemetery, but the economic incentive to participate may be strong enough to override the collective nostalgia that holds us in thrall.

Dr. Bennett is associate clinical professor of psychiatry at Harvard Medical School in Boston. Send correspondence to him at 11 Dunbarton Road, Belmont, Massachusetts 02478 (e-mail, [email protected]).