Joel Yager, MD, is a Professor of Psychiatry, University of Colorado at Denver School of Medicine. He started his career as a US Army psychiatrist in 1969, and has held a wide range of clinical and teaching positions in the intervening years. He has received numerous awards, including lifetime achievement awards from the National Eating Disorders Association (2008) and from the Association for Academic Psychiatry (2009). He has published more than 200 peer-reviewed papers, many of which are concerned with the training of psychiatrists.
In January 2011, Dr. Yager published The Practice of Psychiatry in the 21st Century: Challenges for Psychiatric Education, in the journal Academic Psychiatry. This paper received favorable comment from Jeffrey Lieberman, MD, President of the APA, in the article Training the Psychiatrists of the Future, in the November 26, 2013 issue of Psychiatric News. As my regular readers will know, I am an avid fan of Dr. Lieberman’s, and it is my belief that anything he recommends warrants close scrutiny.
The stated purpose of Dr. Yager’s article is:
“To consider how shifting scientific, technological, social and financial pressures are likely to significantly alter psychiatric practice, careers, and education in the 21st century…”
and to review
“…trends and innovations likely to have an effect on tomorrow’s psychiatrists and their educators.”
It’s a wide-ranging and optimistic article. Here are some quotes, interspersed with my thoughts and observations.
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“Measurement-based disease-management care will progress as even chronically ill psychiatric patients increasingly use computer-based tools in waiting rooms to rate their clinical status before office appointments.”
From his use of the terms “disease” and “ill,” it is clear that Dr. Yager is immersed in the medical model. There is nothing in the article to suggest even an awareness of the fact that this model is under considerable criticism at the present time, nor that this reality may have some relevance for psychiatrist training.
Is there a hint of condescension in the phrase “even chronically ill psychiatric patients”? And is having the client fill in boxes on a computer screen in the waiting room an improvement over talking to him in the office? Will the 15-minute med check be reduced to 10 minutes?
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“Given that psychiatroids [which I think means nurse practitioners, general practitioners, physician assistants, etc., who are authorized to prescribe psychopharmaceutical products] anywhere can virtually manage many psychiatric patients located anywhere, ‘outsourcing’ assessment and even psychotherapy is constrained only by regulatory statutes governing licensing, any of which might be modified in ‘free-trade agreements’ if health systems think they can offer sufficient quality at the right price and manage the political processes and the outcry. With increasing globalization and falling trade barriers, if a strong business case can be made for the economic advantages, couldn’t we outsource elements of psychiatric diagnostic and management? If Walmart and Dell do it, why can’t Humana or Kaiser-Permanente?”
So when a client calls the mental health center after hours, he might find himself talking to someone in India or Nigeria? Provided the “outcry” can be managed, of course.
As to the final question: “If Walmart and Dell do it, why can’t Humana or Kaiser-Permanente,” perhaps the answer is: because helping people with deeply personal troubles and concerns is fundamentally different from selling them laundry detergent and computer monitors. Or perhaps for psychiatrists it isn’t really so different?
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“Certain types of ‘translational’ research favor extra-university settings. Non-academic, clinical-trials organizations, utilizing community practices, have increasingly replaced academic centers for industry sponsored clinical trials (accounting for more than half of such studies). Pharmaceutical and medical-device companies increasingly sidestep delays and hassles imposed by universities’ Institutional Review Boards by employing time-efficient private IRBs. Parenthetically, today’s increasingly restrictive academic zeitgeist regarding Pharma might discourage some excellent clinical researcher-teachers from academic careers and, instead, lead some of the brightest to private practices or industry positions with better financial rewards.”
This isn’t entirely clear, but I think Dr. Yager is lamenting the fact that the belated efforts of university research departments to extricate themselves from the grip of pharma corruption may drive some of “the brightest” clinical researcher-teachers away from academia and into industry positions, where they would be spared the “delays and hassles” of university IRB’s.
But surely the “delays and hassles” of the IRB’s are a reaction to the widespread corruption that existed in university-pharma relationships. The fact is that pharma hijacked academic research and produced an entire generation of bogus research to support and promote pharma’s advertizing message.
Dr. Yager may be correct in saying that the additional scrutiny that is now in place may encourage researchers towards the private clinical-trials organizations. But it reads like he’s also endorsing such trends by pointing out that there will be career opportunities here for psychiatric researchers. Do we have any reason to believe that private research centers, unhindered by the “delays and hassles” of the IRB’s, will be any better able to resist pharma’s corrupting overtures than the universities were just a few years ago? Is it possible to have ethical research without “delays and hassles”? With the recent exposure of widespread corruption in academic psychiatric research, many of us on this side of the debate have wondered if and how pharma would try to get around the new rules. Has Dr. Yager given us the answer?
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“Conceivably, psychotherapies might be prescribed according to individual nervous-system and information-processing characteristics, perhaps based on patient (and therapist) polymorphism variants.”
I tried to picture how this might work, and came up with the following scenario:
Woman; mid-thirties; nervous; enters mental health center; approaches reception desk; asks to see a therapist. Receptionist takes saliva swab from client and puts it into port on computer. Moments later, computer clicks and information appears on screen.
Receptionist: “OK – your therapist will be Phil Hickey, Cubicle 6.”
Client: “Oh, I was wanting to talk to a woman.”
Receptionist: “Well, the computer has assigned you to Phil based on your individual nervous-system and information-processing characteristics. These are derived from your polymorphism variants. Phil is your best match.”
Client: “But I need to talk about very sensitive stuff. Couldn’t you assign me to a female therapist?”
Receptionist: “Sorry, the computer will kick it out. But Phil is very good. You’ll like him.”
Client: “But I’ve heard bad things about him. All the psychiatrists say he’s a cad and a bounder. And he causes mental illness stigma.”
Receptionist: “Well maybe. But he has the best polymorphism variants for your case. You’ll get along great.”
Client: “I’d really prefer to see a female therapist.”
Receptionist: “Sorry, I can’t help you. You could try Old-Fashioned Counseling. They’re on Seventh Street, next to the old movie theater.”
Client: “Thanks. I’ll try there.”
Receptionist: “OK. We hear that a lot.”
Maybe I’m misinterpreting Dr. Yager. And maybe the scenario I’m describing is ridiculous. But when I started in this business in the 60’s, the idea that childhood misbehavior is an illness to be corrected by drugs would also have seemed ridiculous.
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“Combine genomics, proteinomics, epigenetics, and personalized medicine with pharmaceutical advances, and we have tomorrow’s psychopharmacologists. Focus on cognitive-enhancers, including ‘nootropic agents’ (intelligence-and memory-enhancing drugs); ’empathogens;’ and other ‘hedonics;’ work out the ethical practice boundaries; and you might produce cosmetic psychopharmcologists (not just drug-pushers).”
I don’t understand this paragraph, but the general gist seems to be that psychiatry is going to get a whole lot better sometime soon. I did look up the word cosmetic in my Merriam-Webster:
“cosmetic adj: …1: of, relating to, or making for beauty esp. of the complexion : BEAUTIFYING < ~ salves> 2: done or made for the sake of appearance: as a: correcting defects esp. of the face <~surgery> b: DECORATIVE, ORNAMENTAL c: not substantive: SUPERFICIAL <~ changes> 3: visually appealing…”
Is Dr. Yager saying that psychiatrists in the future will be more focused on incidentals than on issues of substance? And what about those last four words – “not just drug-pushers.” Is he admitting that psychiatrists today are just drug-pushers?
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“Some entrepreneurs might consider the idea of ‘spot-market’ pricing underutilized psychiatric beds and services (think PriceLine during low-occupancy periods). Some might ‘package’ traveling mental health teams to manage psychiatric aftermaths of man-made terror and natural disasters.”
This is truly an amazing notion. I find myself visualizing a kind of mental health clearing house, where one can get a psychiatric bed or a med check at reduced price by calling the 800 number and keying in the dates/times that you will be available. Presumably you’d also have to know your own polymorphism variants!
And the traveling mental health teams “packaged” to respond to disasters anywhere in the world. Sounds like Ethan Watters’ worst nightmare. (Ethan Watters is the author of Crazy Like Us: The Globalization of the American Psyche.)
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“Key to lifelong-learning is ‘critical thinking.’ Educators must ignite and nurture trainees’ ‘crap-detectors’…specifically, their abilities to discern and deconstruct all sorts of propaganda: deceptive research and marketing studies from the ‘pharmaceutical-industrial complex,’ the ‘psychoanalytic-industrial complex,’ the ‘CBT-industrial complex,’ and other special-interest groups. Trainees require proficiency in separating facts from ‘factoids’ and ‘spin.'”
I suppose a good example of spin would be connecting the phrases “pharmaceutical-industrial complex,” “psychoanalytic-industrial complex,” and “CBT-industrial complex” in the same sentence with the implication that they pose equivalent challenges to the integrity and intellectual honesty of psychiatry’s new recruits.
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“First, psychiatry is intrinsically hugely satisfying, offering sustained doctor–patient relationships and deep, comprehensive understandings of humanity, plus attractive lifestyles, regular hours, and a relatively low call-burden.
Second, psychiatry’s treatments are increasingly effective. We have more to offer regarding accountability.
Finally, one of psychiatry’s central contributions, more than many other medical specialties, is to offer meaning. Psychiatry contributes substantially to generating and sustaining the culture’s significant narratives (and myths) regarding human nature. Thanks to phenomenal knowledge growth in neuroscience, developmental psychology, and other bio-psycho-social domains, as our sciences get better, so do our stories. The deep professional satisfactions of psychiatric educators have always included, and will continue to include, helping to synthesize and disseminate the cutting-edge, evidence-based cultural narratives for our trainees and for society.”
To which I can only respond that now I finally understand the term “ivory tower”!
SUMMARY
Perhaps I’m being unfair. The article is essentially a cheer-leading piece. Dr. Yager is clearly keen on his vocation, and perhaps didn’t intend his remarks to be taken so literally or to be scrutinized so closely.
However … he did publish the paper in Academic Psychiatry, a prestigious journal that:
“…features original, scholarly work focused on academic leadership and innovative education in psychiatry, behavioral sciences, and the health professions at large.”
And … when Jeffrey Lieberman, MD, President of the APA, co-authored (with Richard Summers, MD), his ground-breaking piece on psychiatric education – Training the Psychiatrist of the Future on November 26, 2103 – he used Dr. Yager’s article as his spring-board.
So it appears that organized psychiatry takes the article seriously and believes that it has relevance for training psychiatrists of the future.
As I’ve said many times, perhaps we, on this side of the debate, should just scale back our endeavors and let psychiatry destroy itself. It’s doing an excellent job.