Minding My Own Business

"Psychiatry," I was recently told by a speaker, "is fundamentally just another business." I found that remark deeply disturbing. Even if psychiatry—and all of medicine for that matter—is viewed as a business, it certainly isn't "just" a business.

"Your business is what you get paid for doing," the speaker continued. "Good business is to do well and abundantly what you are paid for doing." Of course, in an institutional setting what we actually get paid for is documentation: documenting visits and the delivery of care. Following that logic our "business" is documentation and, from a strictly business perspective, it's not the care that needs to be good and abundant, it's the documentation. The main "business" reason to give the care at all—aside from marketing considerations involving reputation—is that documenting care without giving it constitutes fraud and is subject to severe penalties. And the patients don't have to get better, it just must be documented that they receive the care. Business is business. Follow the money. Caveat emptor. Obviously, as important as documentation may be for a variety of reasons, documentation is not the core of what we are about, and psychiatry certainly must not be allowed to be "just another business."

Rather than being "just a business," the psychiatric specialties comprise a set of professions. As professions, they have crucial values and aims, chief among these being the relief of suffering and the promotion of adaptive functioning in our patients. The psychiatric professions additionally have important obligations to serve legitimate needs of society.

As professionals, we serve not one but three constituencies: our patients who need us (purposefully listed first), our institutions that employ us, and society that licenses and certifies us. We carry the trust of society to use its resources wisely and productively, whether for clinical care, education, or research—and without the support of society we lose our right to do what we do. We carry the trust of our institutions (which were founded for lofty purposes, just read their mission statements) to help them secure adequate resources and to respect their need to remain solvent—for without their survival and support, we lose the structure that allows us do our work (our jobs and our paychecks). And we carry the trust of our patients whose conditions require our services—for without our investment in their welfare, we lose our purpose, our heart, and our soul.

Serving all three constituencies, simultaneously and effectively, has become part of the art of modern psychiatry. I have found this conceptualization helpful in organizing what I am doing at times when priorities seem murky. Only if what I am doing serves all three well am I on the right track and able to spend my time relishing my own profession, rather than minding my own business.