As if the news were just breaking that psychiatrists are no longer a source of therapy but more like expensive Jersey toll booths on the pharmaceutical highway, the NYT has run this piece about the struggles of Dr. Levin, disillusioned psychiatrist, and his wife, therapist turned high-volume office manager, who both just had to give up on quality patient care to attain the lifestyle to which they had aspired. The market made them do it. And if you have a problem with that, don’t go crying to them about it. Unless you want the same treatment as this guy:
Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.
But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”
I think the guy started drinking again and then his wife started yelling at him. But that’s the problem with addiction–it messes up our sense of cause and effect, makes us blame external circumstance for our condition, and as psychoanalysts used to say, masks the underlying problem: narcissism. But back to Dr. Levin:
[A few decades ago] like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart….Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. “I had to train myself not to get too interested in their problems,” he said, “and not to get sidetracked trying to be a semi-therapist.”
According to the article, “Talk Doesn’t Pay, So Psychiatrists Turn to Drug Therapy,” “Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.” So Dr. Levin is NOT to blame. Just ask him:
“At first, all of us held steadfast, saying we spent years learning the craft of psychotherapy and weren’t relinquishing it because of parsimonious policies by managed care,” Dr. Levin said. “But one by one, we accepted that that craft was no longer economically viable. Most of us had kids in college. And to have your income reduced that dramatically was a shock to all of us. It took me at least five years to emotionally accept that I was never going back to doing what I did before and what I loved.”
He could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, “I want to retire with the lifestyle that my wife and I have been living for the last 40 years.”
“Nobody wants to go backwards, moneywise, in their career,” he said. “Would you?”
Oh of course not. None of us reading this have seen our earning power decline year-by-year while we keep providing whatever service we feel ethically committed to provide. So I had a bright idea that maybe Dr. Levin could get a talk therapist into practice with him, one who could provide the therapy while he did the drugs, you know, somebody to compensate with the dough. And it turns out his wife IS a therapist. But that was naive of me. She can’t hang it either, and it’s obviously not her fault. She had a better idea about entering her husband’s embattled practice–to become his office manager instead:
Ms. Levin created accounting systems, bought two powerful computers, licensed a computer scheduling program from a nearby hospital and hired independent contractors to haggle with insurers and call patients to remind them of appointments. She imposed a variety of fees on patients: $50 for a missed appointment, $25 for a faxed prescription refill and $10 extra for a missed co-payment.
As soon as a patient arrives, Ms. Levin asks firmly for a co-payment, which can be as much as $50. She schedules follow-up appointments without asking for preferred times or dates because she does not want to spend precious minutes as patients search their calendars. If patients say they cannot make the appointments she scheduled, Ms. Levin changes them.
“This is about volume,” she said, “and if we spend two minutes extra or five minutes extra with every one of 40 patients a day, that means we’re here two hours longer every day. And we just can’t do it.”
She said that she would like to be more giving of herself, particularly to patients who are clearly troubled. But she has disciplined herself to confine her interactions to the business at hand. “The reality is that I’m not the therapist anymore,” she said, words that echoed her husband’s.
Thankfully, despite these struggles, the Levins apparently found the means to ensure that their son could enter a helping profession. And he weighs into the discussion:
In a telephone interview from the University of California, Irvine, where he is completing the last of his training to become a child and adolescent psychiatrist, Dr. Matthew Levin said, “I’m concerned that I may be put in a position where I’d be forced to sacrifice patient care to make a living, and I’m hoping to avoid that.”
I hope the Levins have enough to enjoy their retirement. I can’t tell, though. According to the article, Dr. Levin declined to disclose his income.
Photo credit: anolobb