Keeping the Customer Satisfied



Recently, a Dr. S. Brown wrote in Medscape:

"A while ago, a patient called me to say he couldn't believe I charged him $50 to tell him he didn’t need a chest X-ray. He was a was a 30-something male patient who had had a cough for a few weeks. He had a short visit, wherein I took a brief history of his illness, did his vital signs, listened to his lungs and told him he probably had a viral bronchitis but didn’t need antibiotics or a chest X-ray; his condition would improve with time. He felt he had been overcharged.

I find it increasingly frustrating to do the right things for patients who feel they are being shortchanged if they don’t leave with either a prescription or a requisition. I attempted to explain to him that I make my living mainly by giving professional advice, not by pushing drugs or ordering tests "

The fact that patients seem to demand a prescription when they go to the doctor has led to such things as the overuse of antibiotics. Viruses, which cause a significant percentage of infections, do not respond to them; only bacteria do. Doctors want to keep patients happy, so often will prescribe them even when they know the patient has a viral infection which will clear up all by itself.  The over-prescription of antibiotics, in turn, has led to the emergence of highly antibiotic-resistant bacteria.

Psychiatrists have taken a lot of heat in some quarters for being overly quick with a prescription pad.  If you go to a psychiatrist, you are in fact very likely to leave with a prescription whether you need one or not.  However, some of this situation is accounted for by patients who demand a medication to solve every problem.  It is not due just to psychiatrists being overly enthusiastic about the wonders of modern medicine.

Not that wilting in the face of a patients' demandingness is a legitimate excuse for the doctor to prescribe drugs for everyday problems in living.  Doctors should be prepared to give patients their honest opinion, whether the patient likes it or not.  If the patient gets upset because the doctor says they need individual or family therapy - or perhaps even no treatment at all - then so be it.  If the patients go away angry and see someone else to get a different opinion, that is their perogative.  There is enough legitimate business to keep psychiatrists busy.

Nontheless, what happens if such a patient goes on some website and gives the doctor a bad review, or creates some other kind of negative publicity?  The government has even discussed the use of patient satisfaction surveys for evaluating a physician's "performance."

What if an insurance company demands a diagnosis or refuses to pay for the doctor's negative evaluation?  I do not know for sure if any managed care company has tried to pull that trick, but I have heard tell about it. 

If that happened to me, I would call the insurance company and demand payment, and immediately resign from that insurance company's provider panel if turned down, because I have to spend time doing an evaluation to find out whether or not a patient needs treatment.  I deserve to be paid for my time.

I can nonetheless appreciate how some doctors can succumb to the temptation to take the easy way out and give patients and insurance companies what they seem to want.  Medicine is a business, and alienating potential "customers" can be a poor way to stay in business.

The medicalization of behavior problems has may causes, and the demands of patients for quick and easy solutions to every problem has to be counted among them.

Psychiatry Bashing

Anyone who follows this blog or who has read my new book is well aware that I am highly critical of many of my colleagues in the mental health professions. Drugs are prescribed inappropriately and dangerously, diagnoses are made cavalierly and without considering all the evidence, relationship problems and family dysfunction are ignored, and some therapists think that an unresoved Oedipus Complex is the final common pathway for all mental and behavioral problems, or that food pellets and electric shocks are more important than relationships in shaping human behavior.

Furthermore, I have written about how many so-called psychiatric "experts" are in bed with the pharmaceutical companies and how managed care insurance has done its best to devalue all psychiatric treatments.

My own brother-in-law stated, after he read my book, that on the basis of what I had written he would be reluctant to consult any mental health provider.

Nonetheless, I know that there are a lot of ethical and competent psychopharmacologists and psychotherapists doing fine work out there.  They have just become a bit harder to find.  In my book I tell the reader what to look for when they first visit a new clinician.

Folks, there is more than enough blame to go around for the current troublesome trends in the mental health field.  Another party also worthy of blame is the American public.  In fact, none of the horrible practices in mental health could have taken root without the American public's enthusiastic support and participation.

Consider the following: a lot of people these days seem to be looking for a quick cure for everything. For all the anti-drug hysteria in this country, people want to be medicated for everything. Do the hard work of therapy on your relationships? It's too much work!

Distracted at home or at work?  Taken an Adderal.  Doctors will hand them out like water.

As one psychiatry blogger, FunPsych, pointed out, "...many Americans, if given a choice between exercising for an hour a week versus taking a weight-loss pill, would choose the pill...Furthermore, Americans are already overworked and feel pressured to work even more. At least half the patients that I've seen that I want to do therapy with just don't have time for it."  Or so they say. 

Kids out of control? Do most parents want to look at their own parenting practices to see if they are contributing to their children's behavior problems? Some may write to get free advice from the Supernanny and get on TV, but I've already placed several posts about the answer to this question.  Rampant child abuse and neglect?  Nothing but implanted memories and false accusations, according to many.

A psychiatrist who wants to do the right thing can go bankrupt.  If a resident fresh out of training is looking for a job, he or she will find this situation as described by another psychiatry blogger, Pacificpsych: 

"Show me one [psychiatry] job in the entire US ... that entails psychiatrists doing therapy. The entire system consists of psychiatrists being forced to medicate, as well as them being controlled by insurance, UR people, nurse admin, non nurse admin...Show me the clinics or hospitals where you can get a job doing anything else but medicating patients." 

Rehabilitation for schizophrenic patients instead of just meds?  The public will not pay for it, and therefore it has become nearly non-existant in the public sector, and almost as rare privately.

Mental health is the first thing that is cut when state finances get tight?   Why?  I'll tell you why.  Because the mentally ill do not vote, and most of the public does not give a sh*t.  Because many politicians seem to think the mentally ill are all slackers, agreeing with the rabid antipsychiatry zealots (more on them shortly) that all mental illness is a myth. (How ironic that Ronald Reagan suffered from a mental illness - Alzheimer's disease - for the last part of his life).

And then we have the antipsychiatry lot who seem to be incapable of making any distinctions at all. All psychiatric drugs damage people and do nothing else, according to these people.

Apparently they believe there is some vast worldwide conspiracy to ignore the supposed horrific dangers of, say, antidepressants (which have been in use since the 1950's), and that the FDA as well as legitimate FDA watchdog groups like Public Citizen (not to be confused with Scientology's Citizens Commission on Human Rights) have somehow completely missed the millions and millions of patients around the world who have been destroyed by these widely-used and popular drugs.

But we know the FDA is completely in the hip pocket of the pharmaceutical companies.  (Of course, the FDA put a "black box" label on antidepressants on the basis of rather minimal evidence warning of potential suicidal ideation caused in teens and children.  How did that ever happen?)

I received a few comments on one of my blog posts by one reader that I decided not to post. I'd like to share some of them here: 

"Psychiatry is an evil profession, and you know it...Psychiatry has changed very little since 1938, when it was the training ground for the SS - exterminating up to 100,000 German citizens who were deemed "mentally ill" with 'special treatment'...Is psychiatry an evil profession? Absolutely...

I looked [at your blog]. What I found was the writing of a guy who wants to be different from his peers, but isn't. You have very little respect for people who suffer. One minute, describing how their condition is related to past trauma, the next minute ridiculing their behavior. You wrote the book on personality disorders, it appears. Yet your own personality is about as twisted as any person I've ever read...You seem to be a very miserable person, an abusive person...Your arrogance leaves me nauseated...You are an abuser, and YOU KNOW IT !!!!!!!!!!!!!!!!!!!!!!!!!!!!!"

Let's see. If I use a little snarky humor or exaggeration in a blog in order to make a point and to entertain readers (guilty as charged!), then of course I surely must consistently and abusively ridicule my own patients. I suppose I should never see any black humor in my patients' horrible predicaments; if I had any empathy at all I would be depressed along with them. (That's what patients really need: a doctor who is as depressed as they are).

This guy says I am a knowing participant in an evil profession. Psychiatrists like me who have committed people who are a danger to themselves or others are no better than the Nazi psychiatrists who helped exterminate the mentally ill during WWII.  Yes, I know all about Ernst Rudin and the eugenics movement - you will find an interesting discussion of it in Chapter One of my new book.   I guess that makes me a Nazi. There will undoubtedly be a picture of me with a Hitler mustache on some placard someday.

He accuses me of all these horrible things and yet he tells me I am abusive? That's rich! Pot, meet kettle.

Are patients who are terrified by persecutory delusions and hallucinations and who are found running nude on the freeway by the police better off in jail, where many of them in fact are now, or on Skid Row, than in a hospital? 

Pacificpsych also said, "...even psychiatrists who are completely opposed to the current system have no power to change it. They are trapped, unless they are in private practice and doing well there. YOU, yes YOU need to help us. Go to the administrator of the clinic, call the health insurance/medicare/medicaid administrator, call your senator and congressman. Demand that you get proper treatment. That means spending as much time with your psychiatrist as you and your psychiatrist feel is necessary..."