Talking about Talk-Therapy, A Doctor May Have Mangled His Own Words

A March 5^th front page story in the New York Times was headlined: “Talk Doesn’t Pay, So Psychiatrist Turns Instead to Drug Therapy.” My first reaction was: why is this front page news, or news at all? The article focused not so much on the changing nature of psychiatry and the long-standing scientific debates between the merits of psychotherapy versus psychopharmacology, but about the economics of it all. That isn’t news either. Anyone who has read anything about reimbursement in the past few years, knows that it is much easier to get reimbursed for using a sophisticated imaging device than for spending time trying to diagnose a patient through physical exam or conversation.

When the article said that psychiatry has suffered more than any other specialty when it comes to reimbursement, I felt their pain. I feel sorry for doctors who are not compensated for what they were trained to do. I understand why they must be depressed. And I feel badly for their patients who may no longer be able to afford the psychotherapy they need.

And yet, by the time I finished this rambling piece, I was thinking less about the state of psychiatry and more about the one doctor profiled, and hoped that he isn’t the norm, but an outlier. The piece focused on Dr. Donald Levin, a psychiatrist, and his wife, Dr. Laura Levin, a social worker, who are so disgruntled by the state of affairs, they no longer seem to care about their patients the way we wished doctors would. Dr. Levin spends 15 minutes with each patient, juggling their medications. He no longer offers psychotherapy. Ms. Levin manages the business and provides the talk therapy, if needed.

Here’s a sampler of a few of the Levins’ comments:

· He said he could have accepted less money but “I want to retire with the lifestyle that my wife and I have been living for past 40 years.”

· His wife said that when patients arrive, the first thing she asks is for the co-payment. “This is about volume,” she added, “and if we spend two minutes extra or five minutes extra with every one of the 40 patients a day, that means we’re here two hours longer every day.”

· Dr. Levin does not have time for patients to tell their story, but rather he fires questions at them. “And people want to tell me about what’s going on in their lives as far as stress and I’m forced to keep saying: ‘I’m not your therapist. I’m not here to help you figure out how to get along with your boss, what you do that’s self-defeating, and what alternative choices you have.”

· In response to hearing that a lot of his patients truly appreciate his brief sessions to keep them up on their medications, he said: “The sad thing is that I’m very important to them, but I barely know them, I feel shame about that, but that’s probably because I trained in a different era.”

It is shameful, indeed. I understand that the Levins are upset with the system and they have good reason to be. But I would have hoped that a physician talking to a New York Times reporter would be savvier and more careful with his words that are going to interpreted by a huge lay readership. Dr. Levin, on the front page, became an ambassador of sorts, for all of medicine. And anyone outside the system would think that all doctors want is a way to make a quick buck and get the patients out the door so they can get home by dinner.

The trick is going to be how to shape the future of medicine when so many of our burgeoning young doctors are graduating from medical schools that offer electives (some are even mandatory courses) in the humanities, ethics, and doctor-patient communication. Let’s hope that the new breed of caring physicians, entering into difficult economic times, will not lose sight of the most vital element of every single medical specialty: the patient. And while listening takes time, and yes time is money. I hope that most doctors continue to think it’s worth it. And I hope our insurers will too.