Practicing at the Top of Your License



David Mintz, MD

This year, at the American Psychiatric Association (APA) Annual Meeting, I heard a new catchphrase: "practicing at the top of your license." While I had heard this phrase a few times before, it seemed to be everywhere this year. The context in which this phrase tended to be uttered was when psychiatrists were describing the position that their employers took, when those psychiatrists wanted to provide some form of psychosocial treatment in addition to (or as an alternative to) the model of "15-minute med checks." The implication seemed to be, "you are medically trained, while others are not, so your energies should be devoted exclusively to providing medicine."

I have to say, that I agree that it is a good idea for psychiatrists to be practicing at the top of their license. I disagree profoundly, however, with that narrow notion of what it means to practice at the top of the psychiatric license. With regard to the prescription of psychiatric medications, it is arguable that psychiatric prescribers without specific training in psychiatry might be practicing at the top of their license in focusing primarily on the clinical task prescribing medications.  

Intensive psychodynamic psychotherapy at the Austen Riggs Center.

Psychiatrists, on the other hand, have all received training, to the level of "competence," in various psychotherapies. What sets psychiatrists apart from primary care providers, psychiatric nurse practitioners (NPs) and psychiatric physician assistants (PAs) on the one hand and from psychologists (in most states) on the other, is that psychiatrists have been trained in both psychotherapy and pharmacotherapy, and in the integration of the two modalities. This, to me, is clearly the top of the psychiatric license: to know how to integrate psychotherapy and medications in ways that enhance outcomes, and to know which patients would benefit most from combined treatment.

My admittedly cynical suspicion is that the aforementioned employers are, at least in part, using the phrase "practicing at the top of your license" to guilt or shame those psychiatrists who want to do psychotherapy into providing the kind of treatment that maximizes income for their employers (and, less cynically, also allows them to see as many people in need as possible). These employers seem to equate the “top of the license” with top billables, and represents one of the ways that the reimbursement tail wags the clinical dog.

Their psychiatrist employees, however, are truly the ones who desire to practice at the top of their license. They recognize that many patients are unable to benefit from medications alone due to the complex nature of their troubles, and often in the context of disturbed relationships with medications, with treatment, with caregiving, or with health itself. In this era when pharmacologic treatment resistance is increasingly recognized as a tremendous clinical problem, these biopsychosocially trained psychiatrists recognize that, for a great many patients, psychiatry is most effective when it is able to combine psychotherapeutic skills with pharmacotherapy.

Psychiatrists should perhaps embrace this new catchphrase, insisting on working at the top of their licenses, but pushing back against the narrow, cynical, and unproven idea that the top of their license involves throwing away half their training and half their skills.

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