The Medscape psychiatry specialty page posted some physician responses to an editorial entitled The Disappearing Patient in which the author notes that, for example, the monthly "green journal" contains nothing that pertains to an average psychiatrist's practice: "Psychiatry is teetering on the edge. Does it really want to become neuroradiology lite, and give up its traditional role of connecting patient experiences to social realities?" he asks. One psychiatrist's response struck me as particularly poignant:

Due to chronic pain, I've developed an interest and practice combining acupuncture/energy treatments with more standard psychotherapy/ medication strategies. I think our profession is missing an opportunity to expand how we address emotional disorders. We're too locked into neurotransmitters to see beyond the synaptic cleft. (That is a joke.) Working with energy fields helps medication become more effective. Unfortunately, most professionals see this as an either/or proposition. Either Western medicine or alternative. But not both. (Both is what has enabled me to keep working and not go on disability.)

I've approached psychiatric institutions (some academic, some with "complementary departments") without response except from the residents I've presented to. They're enthusiastic. But not those who set the agendas. Like many repressive traditions, psychiatry now holds fast to "truths" that falsely assure a footing in the healthcare consumer scramble.

To me, we're being narrow and defensive about an area that could breathe new life into a field that has been robotized into symptom checklists and diagnostic codes. Where's the passion? When I trained in psychiatry eons ago, we weren't afraid to creatively embrace what was not already approved of. Fritz Perls, Milton Erickson, anything was considered game if it might be effective. In my view, the times have changed and our courage has faltered. What we seek now is to reduce treatment to a no-fault formula or algorithm. In doing that, we dismiss intuition and the individuality of both patients and ourselves. Frankly, psychiatrists don't need to commit suicide. They will die of boredom.

I have friends and colleagues who see up to 40 patients per day (albeit Medical patients, CA's version of Medicaid, which pay approximate $16 per visit) for "medication management." Further, there is a complex matrix to billing psychiatry visits: initial consultation; short, medium, and long visits; with or without medication consultation, blah, blah blah. The ultimate question is, of course, what will your insurance pay? I would hate to imagine that which service is billed (whether you received it or not) depends upon what a given carrier will pay, but I certainly would not be surprised. I lost a patient who was personally billed $74 by Medical, in error, for a 50-minute session he had with me; "How dare you?" he screamed at me on the phone. "That's a third as much as my monthly student loan payment!" I didn't scream back. I recall an attending taking a patient into his office as I prepared a cup of coffee. As I began to stir the coffee, the "med management" patient was leaving and I noticed the attending was already back to reading the morning paper. Who knows if this included a referral to a psychologist to manage "issues." But do the math: $640 for less than 3.5 hours of "work." Satisfying? I never ask. And what if psychologists receive the right to prescribe psychotropic medication?

In the environment of a major research university, I am quite familiar with the sentiment of the author of the Disappearing Patient. The prized NIMH funding, as well as the bolster to the department's reputation, has virtually no impact on the daily activities of "non-researchers." And while we cannot measure the future impact of what current research might reap (and this university is bordered by "Nobel Drive" for a reason), it seems that the sentiment of the Disappearing Patient is an age-old opinion (and insecurity) that psychiatry is not really "medicine."

As the author of Disappearing Patient notes:

Many correspondents [to the editorial] were concerned with the impact of this excessive biological reductionism on patient care. This includes a lack of self-observation: as one psychiatrist said, "So many of the practitioners of psychiatry today have never turned an eye inward, that the profession is becoming populated with psychiatrists who cannot self monitor." Beyond that, as a psychologist in the Midwest United States observed, "the local psychiatrists rarely hear anything the patients' families tell them, nor do they seem to care. If the patient's difficulties are in a great part emotional/social/environmental, rather than purely biologically based, psychiatrists locally do more harm than good." A patient with treatment-resistant depression described a fruitless trek from one doctor to another. "The person in here," she said, "has been ignored in 'the collusion of anonymity." These letters reflect what I believe to be a strong current of dissatisfaction with today's reductionistic psychiatry, emanating from "consumers" as well as "providers." They describe a variety of adverse effects from such a model of practice. These include the often-irrational limits imposed by managed care and reimbursement policies.