Talk Therapy Vs. Fewer Dollars and Less Time

GUEST: Dr. Robert Michels
AIR DATE: 07/30/2011
VTR: 04/28/2011

I’m Richard Heffner, your host on The Open Mind.

And you may have noted some time back a particularly attention-gathering front page story in the New York Times … one that provoked some readers to decry what they thought to be sensationalism mixed with a rather ho-hum, what-else-is-new message … and some others simply to deplore that message itself: that in large measure because of changes in how much insurance will pay, many of the nation’s 48,000 psychiatrists now no longer provide talk therapy – which the Times story calls “the form of psychiatry popularized by Sigmund Freud [and] that dominated the profession for decades” — instead, simply prescribing medication, usually after a brief consultation with each patient.”

As the Times wrote, “Medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations.

“But the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry.”

Which, of course, reminded me of June, 1975, when today’s Open Mind guest first joined me to talk about quantity versus quality in psychiatric treatment.

Now, 36 years and a dozen and more Open Mind conversations later, having served as Chair of its department of psychiatry and as Dean of the prestigious Cornell Medical College, Dr. Robert Michels is Walsh McDermott University Professor of Medicine and University Professor of Psychiatry, Payne-Whitney Clinic, New York-Presbyterian Hospital, Weill Cornell Medical College …as well as one of the nation’s most eminent practicing psychoanalysts.

Now, of them all, I think my favorite program with Bob Michels came in the 1990’s, one I waggishly titled “Psychoanalysis And Its Discontents” and introduced with the notion that there was “trouble in Paradise”.

Indeed, I’ll begin today by asking my guest whether the recent Times story – along with the comments it elicited – might not indicate that now there’s even more trouble in paradise, and that psychiatry’s troubles today may be somewhat more than even it can talk through. What do you think, Bob?

MICHELS: Well, I read the story. And along with my colleagues, we were horrified by the picture it painted.

Psychiatry has troubles, largely they are troubles of medicine across the board, not only psychiatry. And although I think the story was a caricature … unfortunately like lots of caricatures, it was a caricature of something that’s really there.

There are good things as well as bad things in the story. There was a time, fifty years ago, when psychiatrists only talked to patients because there wasn’t much more they could do except talk to patients.

We didn’t have effective medication that was safe and was valuable enough to be worth its side effects. We didn’t have other forms of treatment we could use.

Talking is a good treatment and it was effective, but we longed for things that were even better.

Since that time we’ve developed better treatments. For the most part, we’re most effective with most patients when we used combined treatments … talking … sometimes medication … other treatments.

But there’s immense pressure from the administration of health care … the insurance industry, people concerned with cost saving … to deliver not the best treatment and not the most desirable treatment …and not even the most effective treatment, but rather the cheapest treatment.

And unfortunately cost is measured not in terms of cost compared to benefit, but simply cost. And the cheapest way to treat somebody is to see them as little as possible, to talk to them as little as possible, even worse … to listen as little as possible … and maybe to write a prescription, hand it to them … like the man in the Times article.

Unfortunately, it’s bad medicine, it’s bad psychiatry, it’s bad public policy, public health, because it doesn’t work very well and it’s humanly offensive to people when you think of someone in distress … wants to share an experience, have a friend and is deprived of that.

HEFFNER: But it’s not really bad reporting, is it? Because it does tell a tale that has some very real basis for truth.

MICHELS: Well, I’m not a reporter. I would say it tells a tale that is a … immense exaggeration of a theme that we should all be worried about, but for the most part is not true today, although there are scary suggestions that it may become true in the future.

Frankly there’s an aspect of this that worries me more than anything else. My colleagues don’t practice that kind of psychiatry and my students don’t practice that kind of psychiatry.

But articles like that and the pressures that that doctor was under change the kind of people who want to go into medicine, who want to become psychiatrists.

I’m worried about my grandchildren’s psychiatrists if they select the field thinking that that’s what it’s like … they’re not going to be the right people to be in the field.

HEFFNER: That’s an interesting point of view and I have to ask you immediately, whether you see any indication in those who do go into medicine, who do opt for psychiatry that there is a movement in that direction.

MICHELS: I would say we’re today getting about 4% of American medical school graduates go into psychiatry.

HEFFNER: That much?

MICHELS: Yes.

HEFFNER: I’m surprised.

MICHELS: 4%, that’s been pretty constant over the last decade. And we get the brightest and the best since I’ve been in the field and when you and I first did this in the seventies … I was already in the field for a decade.

So, it’s been a while and I’ve seen them over the years. And we couldn’t do better, frankly in my experience.

But I think their expectations of what medicine is about and what psychiatry is about are gradually changing. And that’s disturbing.

Being a physician is not a job. You don’t want to be taken care of by a doctor who thinks he’s an employee and is filling out his obligations from nine to five, Monday through Friday.

It’s a calling. A vocation in the literal sense of that. There’s something sacred about it.

And if we do away with that, with a healthcare system and a financial system that makes the doctor an employee like any other employee in a large corporation … we’re going to hurt health care and hurt patients.

HEFFNER: Do you think that’s happening now?

MICHELS: It … there are … it is happening to some extent; it’s terrifying that it might happen increasingly before we do things to stop it and control it.

And I’d say two things about it. One is, although it’s … the motive behind it is largely cost saving … it in fact doesn’t’ save costs because it’s lousy medicine.

The quality of the physician/patient relationship, including, but not only the psychiatrist’s patient relationship, is a major determinant of the efficacy of treatment … the outcome. So we may save money on the bill for the treatment, but we don’t save money when you take into account the fact that the treatment isn’t as good if it’s delivered by a machine.

And again particularly disturbing … we want a profession that appeals to the kind of people in our society who we’d like to see become doctors. And if we make a profession that less attractive, we’re going to pay a price for many generations.

HEFFNER: Well, question … obviously is … what are we doing … if anything?

MICHELS: Well, we’re doing some good things. As you know the nation is in the throes of a major national dialogue about how its health system should be reformed.

One of the disasters of our health system has been that there are people who don’t get health care, and we’re the only advanced country where that’s true.

And there are major attempts underway to change that. To make sure that everyone in our society gets health care whether they have the money to afford it privately or not. That’s a positive change.

We also know that it’s important that all physicians are trained to understand the importance of the psychological and social, as well as the biologic aspects of health problems.

And that education is more and more built in to our medical school training and that’s a very positive change.

But unfortunately our reimbursement system … by insurance companies, by Federal coverage for Medicare and Medicaid are increasingly geared to units of care delivery, rather than to comprehensive care over the course of an illness or the lifetime of a patient. And I don’t want a doctor who treats me for fifteen minutes, because I had the 15 minute treatable disorder.

I want a doctor who I know over a period of time, who when I call him up when I’m sick, knows who I am, who when I’m dying … has known me over a period of time and understands what’s important to me, to my family, to my culture and who gears the treatment to those kinds of values. And you can’t buy that in 15 minute units.

HEFFNER: How likely is it that someone who says just exactly what you’ve said about what you want … wants exactly the same thing. How likely is it that that person is not going to find that in America in the future?

MICHELS: Well, I would say the first answer … the one that I’m more confident of is it’s fairly likely he won’t find it today.

The future’s harder to predict. (Laugh) I forget the origin of the line and you know these things, Richard, but after we do everything wrong, we’ll finally come around to doing it right.

HEFFNER: Ahh.

MICHELS: I think that’s probably true. And I think that in this field where we have good … a good capacity to measure the results of what we do, we’re going to discover … with scientific research … that it’s more effective to be humane than to be crisply cost accounting.

HEFFNER: You’ve changed in the last 36 years. I don’t think you would have said that when we first talked together. Would you?

MICHELS: I’m trying to remember what I said 36 years ago.

HEFFNER: Oh, I don’t mean this …

MICHELS: One of the changes is … I can’t remember.

HEFFNER: Ha, ha. Bob, you’re expressing something so optimistic. And to me, I’m afraid, so unrealistic, so contrary to fact that I’m surprised.

MICHELS: Right now the country’s in a difficult period of economic stress and I don’t think you’re going to see a move toward more optimal public policy that costs more. In the short term.

But I think in a society like ours, there are not many values that we hold higher than good care for our sick, for our disabled, for elderly.

And the health professions are invested with delivering that care. I think when our resources become less constricted that’s going to be apparent to all as a very important goal for our society.

HEFFNER: Said, when our resources become less restricted or constricted …

MICHELS: Yes.

HEFFNER: … you see that in the future?

MICHELS: I’m not an economist, but I do see that in the future. It seems to me that we’ve had waves in our history … recurrent waves in which our resources are constricted. And we’re coming out of one now or maybe we’re still in the middle of it, but I think if we can think ahead a decade or two … yes, I do think that’s going to happen … and I think as that happens … as our advances in science and technology create more capacity, more wealth … what other goals are we going to spend it for?

HEFFNER: Well, I would ask … turn that around and ask you … you’re, I know, the philosopher as well as the psychiatrist … in terms of your practice, let’s take these years since we first sat at this table … do you find Americans moving more toward that level of generosity toward others that you’re really expressing now? What else would we turn our attention to other than the well-being, the health of the old, the poor?

MICHELS: Well, I think the first step is … I think we very consistently want that for those close to us.

HEFFNER: Yes.

MICHELS: Our children, our parents, our families. And I think less consistently, but still considerably, we want it for those who are members of our shared community … however we define that … culturally, ethnically, religiously, geographically.

HEFFNER: And the others?

MICHELS: And we’re less sure of the quote … others. But I see one change as being … that the group that we think of as others … is shrinking some. And the group we feel are part of us … is increasing.

You see it in changes and attitudes toward other cultural or ethnic groups … toward other … people with other sexual orientations. We live in a world of friends. And increasingly, I think, particularly as our kids grow up in schools that are integrated and neighborhoods that are integrated … if … we see more and more inter-marriage amongst cultures … there’s no “other” left.

HEFFNER: You know there’s this pause, this pregnant pause because I’m thinking … “Is this the Bob Michels who I would have always identified as primarily brilliant … next cynical … and next realistically cynical”. You’ve changed then. You’ve changed your picture of the world. Or has my picture of Michels been so wrong?

MICHELS: Well, I have grandchildren and I want them to live the kind of lives I want them to live and I want the world to be the place where they can live those lives.

HEFFNER: So is this an observation or is this telling me what Bob Michels wants and hopes for. Seriously.

MICHELS: Well, it’s both. Because I don’t think I’m that different from most people in what I want and what I hope for.

And, again, I think as the society has more resources, those values become more possible to fulfill and fewer sacrifices are required to fulfill them.

I remember a couple of decades ago when the dialogue was going on about the Clinton proposals for changes in the health care system. And I was quite involved with that.

And I had a meeting with our former Senator, Pat Moynihan, who I’m sure you knew …

HEFFNER: Mmmm.

MICHELS: … and we were talking about the … all the terrifying projections of the percentage of the gross national product that went for healthcare. And Moynihan pointed out … what else do we want it to go for? (Laughter)

We should have a higher percentage of our gross national product going for health care. It’s the one thing that we can buy more of … do we want faster automobiles on our roads? Do we want more sugar in our food? Or do we want better healthcare?

Clearly, as we become more affluent, the percentage going for that kind of enrichment of life, should go up. And I believe it will.

HEFFNER: We’re talking about attitudes and I, I repeat the question. As a psychiatrist, as a practitioner … as a person who’s sat opposite so many people or had so many people lying on the couch … whatever chemicals were involved in, in the process … do you find … can you say now … this is a more benign society than when you started your practice.

Can you, can you really say not that you hope all these things are true, but you’ve seen them, you’ve seen this … the attitude that Pat Moynihan expressed … that you’re expressing.

MICHELS: I would say in a funny way a psychiatrist is the least likely person to know the answer to that question.

When someone comes to see me, they don’t talk about the world. They don’t talk about society and social ills, they talk about very close personal things. Their families, their children, their trouble with physical illnesses, their financial problems. People don’t go to a psychiatrist to talk about the future of healthcare or the nature of the economy or the values of the public society.

But I will say this, the vast majority of people that I’ve seen from the beginning … if I … and you learn somebody pretty well when you’re a psycho-therapist or a psychoanalyst … they … people tell you the truth because they have a very strong motive to tell you the truth. Most people are inherently very good.

HEFFNER: You see I’ve learned something new about Bob Michels, or I see something different … or you’ve changed.

MICHELS: Well, maybe both.

HEFFNER: It so interesting what you say about … you’re a grandparent now … and you’re thinking about the world in which your grandchildren will live.

I feel that way and I fear … about fear so, so strongly about the world that my grandchildren live in and will live in. It’s good to find you setting me on what I hope is the right track, even though I’m a bit suspicious.

MICHELS: Well, I have two granddaughters. They’re seven and eleven … this is a little plug because they may be watching … I love them dearly.

They go to a better school than I went to when I was their age. They have a better curriculum, they have toys they play with that were unimaginable tools for industry when I was a child.

They know more about computers than I do. When I have trouble with my computer, my eleven year old tells me what to do with it …

HEFFNER: Sure.

MICHELS: They’re in a world that much richer in the opportunities and in the capacities. And they’re extremely humane in their relationships with their peers and friends and other people and the projects they think are worth doing and the things they want to do when they grow up in the world.

I think that our culture should be valued importantly by our ability to stimulate and develop those kinds of goals, values and motives in our young.

And I think we’ve largely been successful with doing that. I think this is a much better country to live in than it was 100 years ago or 50 years ago.

HEFFNER: That’s a very interesting point to make. A very interesting point to make. And I take it at face value. I’m puzzled by it.

But let’s turn back now to this question that we, that we began with … this, this piece … “talk doesn’t pay, so psychiatry turns instead to drug therapy”. Do you think that’s hyperbole?

MICHELS: It’s hyperbole, but unfortunately not totally without a basis.

HEFFNER: Okay, then if you see, if you look into the future, will that basis … that base enlarge?

MICHELS: What I … and you tell me to be careful to differentiate hope and belief …

HEFFNER: I will.

MICHELS: What I hope for and believe is that what will help us with this is the fact that medicine in general and maybe psychiatry in particular has moved from being based on tradition, on folklore, on doing what your teacher taught you to do, to being based on research, on knowledge on the scientific assessment of the efficacy of various treatments and interventions. And good science tells us that that is bad medicine.

And that good science will lead to a demand by the public and a response by the insurance industry and the government to make sure that our system of reimbursement and of coverage for healthcare allows high quality care to take place.

It will penalize people who write prescriptions without listening to patient’s problems. Not because it offends us humanistically or aestethetically, which it does, but because it’s bad medicine. It’s like writing the wrong prescription, instead of the right prescription.

If you’re going to take the right care of a patient, you have to know them, you have to let them know you, you have to listen to their problems and you have to design a package that more often than not includes medication and talk in order to help them. And the public will demand the best possible care, just like they want the best antibiotics and the best surgery and the best health care in general.

HEFFNER: You see, that’s, that’s where I find it so difficult to follow you. I understood and I understood initially about the efficiency, efficacy … value of treatment that is based upon a combination of all the modalities that are at your disposal.

I work on the assumption that we know that now and we are still going quickly in a direction that is very different. A direction in terms of what we’re willing to pay as a nation.

MICHELS: I think most people are good. I don’t think everybody’s good (laughter) and there are clearly important forces out there that have a goal that’s greater than the best possible healthcare, and it might be the greatest possible profit for a company providing healthcare. I know that happens.

I may, I may be less cynical, but I’m not really more naïve. However I think that even although that debate is going on, the weapon in that debate that’s going to end up determining the winner is going to be systematic assessment of the truth. And we do have a powerful resource community that can demonstrate what treatment works and what doesn’t.

If there are situations where humanistic care doesn’t make any difference, I’m not sure I would advocate using public dollars to provide it just because that’s my aesthetic. But particularly in the area of psychiatry the data are already in and inhumane care … thank God … is bad care. So we’re going to win.

HEFFNER: Well, you say “inhumane”. You load it right there because we’re not talking about inhumane, we’re talking about less effective. Or maybe you make … the two the same.

MICHELS: I mean things, for example, in the article you’re citing … there’s a mention of the patient saying, “I have a problem I want to talk to you about”, and the doctor saying, “I’m sorry I don’t have time to listen to your problem”.

HEFFNER: Right. He does say, “Go see your therapist”.

MICHELS: I know. But that’s not the right answer and it’s sad that any doctor does that, but most important it’s easy to demonstrate that he’s not doing a good job of treating his patients when he says that. Not only is it something that people reading the article think is offensive. But it’s something that a quality assurance oriented physician would say is a defect in the quality of care.

HEFFNER: Well, Bob Michels, I’m so pleased to have you back here … we’ve talked many times at this table since … 36 years ago … but we’re going to have to come back more often to measure the accuracy of your optimism which you say is based upon our ability now to know what works and what doesn’t.

MICHELS: I’ll forward and I’ll bet you … that when we talk again in 36 years … you’ll come around to see my point of view.

HEFFNER: (Laughter) From your lips to God’s ears. Thanks, Bob Michels.

MICHELS: Thank you, Richard.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. Meanwhile, as another old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.